My Appeal Letter
Jun 15, 2011Here is a copy of my personal appeal letter. "Thank you's" also go out to others on OH, for helping me with this appeal letter. I am posting it here for anyone who should need ideas and information for their appeal letter.
Provider: Essentia Health Service Requested: CPT 43775 – laparoscopic sleeve gastrectomy
This letter is to appeal your denial for laparoscopic sleeve gastrectomy surgery (CPT 43775)
I request a BOARD CERTIFIED BARIATRIC SURGEON be A CONSULTANT on the APPEALS and GRIEVANCE board. Please put this in my notes.
This request is made due to BlueLink TPA (Blue Cross and Blue Shield Association of MN) assessment that the VSG (Vertical Sleeve Gastrectomy) is experimental/investigational which I feel is at best, uniformed, and at worst, a knowing endangerment of my health that could have risk management consequences if I have to have another procedure (namely, the Gastric Bypass) and there is an adverse outcome. I agree with the experts; that the VSG or Sleeve Gastrectomy (SG) surgery is the safest and best weight loss choice for me. I’m confident that after reviewing the attached documentation the committee will agree and grant approval for the VSG. I am requesting an appeal of this decision based on the following:
I. Patient Background
As stated in my original request, I am a morbidly obese female weighing 259.2 lbs, with a height of 5’7” and a BMI of 40.7 with mostly obese related co-morbidities that will improve or go away completely with weight loss. I am hoping to have the VSG surgery so I can have my health and life back. I have been overweight to varying degrees for the last 25 years of my life. I have made numerous attempts at weight loss through these past 25 years including Weight Watchers many times, NutriSystem, protein shakes, Slim for Life Program, Phen-Phen, cabbage diet, low-cal meal plans and many, many more diets. It seems like I would always lose 10-20 pounds, but I would eventually gain the weight back, followed by even more weight. I have several co-morbidities. I have developed High Cholesterol, for which I have been taking Simvastatin. I also suffer from Depression that has been treated with fluoxitine for several years. I truly feel my depression is linked to my obesity because it has lowered my self-esteem, kept me from feeling comfortable around people and stopped me from engaging in many exercise activities. I suffer from GERD, for which I am currently taking Omeprazole. I also have asthma which is controlled with ProAir. After a Sleep Study, it was determined that I did not have Sleep Apnea, but still I had several episodes where I stopped breathing. However, not ENOUGH to be considered Sleep Apnea. Most, if not all of these conditions can be reduced greatly or eliminated with the help of the Gastric Sleeve as a tool to assist me with portion control and weight loss. One of my most important reasons for choosing the VSG surgery is the use of NSAIDS after surgery. It is the only WLS that is considered safe to continue with NSAIDS post operatively. I have been diagnosed with fibromyalgia, arthritis in my hands and bone spurs on both feet, one of which has required surgery, but I still have moderate pain in that foot. Anti-inflammatory medication is needed for reduction of pain and inflammation of all these conditions. Another important aspect for me having the VSG surgery is that in a FANA test, I have been found to be positive for ANA (anti-nuclear antibodies) in my blood. This leads to concerns about future possibilities of rheumatoid arthritis, systemic lupus erythematosus (SLE), Polymyositis and other conditions that may need to be treated with NSAIDS and anti-inflammatory drugs. It has been established that Weight Loss Surgery is medically necessary per my doctors, surgeon and BlueLink (Independent Licensee of the Blue Cross and Blue Shield Association of Minnesota) medical policy and I am grateful Weight Loss Surgery is an option for me. I am even more appreciative of the fact that there is more than one WLS to choose from to accommodate a person’s medical and psychological needs. I have spent years researching different types of WLS and have determined that the VERTICAL SLEEVE GASTRECTOMY is the WLS that is best for me. I am highly motivated to succeed with the Gastric Sleeve and understand that my food intake will be significantly limited for the rest of my life and that I must continue to exercise to be successful. I believe my doctors when they say the Gastric Sleeve it the best option for me, I would not want to take a chance with the Gastric Bypass or the Lap Band because of what I feel are very high complications rates, which include dumping, strictures, ulcers, bowel obstructions, anemia, vitamin/mineral deficiencies, slippage of the band, erosion, port problems or device malfunctions. This is the WLS that will allow the most normalcy post-operative.
II. Supporting Literature
Partial Gastrectomies have been done on patients suffering from stomach cancer and peptic ulcers for well over 100 years so we know a patient can live successfully with part of the stomach removed. The first gastrectomy was performed by Theodor Billroth in 1881 on a patient with antral carcinoma. The procedure itself has been of course modified and improved over the years just as the original Vertical Gastroplasty of the 1970’s and 1980’s has made the pathway for the significantly improved Vertical Sleeve Gastrectomy. VSG was first performed in 1993 by Dr. Jamieson in England and has since been refined and improved into the VSG we know today by Dr. Gagner in 2001. The VSG has been performed for 15 years and as we know it today for the last 7 years. This is a far cry from an investigational surgery. The results from the studies speak for themselves as well as the people I correspond with on a daily basis on Obesityhelp.com forum- (http://www.obesityhelp.com/forums/vsg/). Here you can see the real life examples of the success of the VSG with weight losses in excess of 100 lbs with no major complications post operatively. A review article entitled “Systematic Review of Sleeve Gastrectomy as Staging and Primary Bariatric Procedure” [RL1] was recently posted on the web site of the American Society of Bariatric and Metabolic Surgeons dated May 26, 2009. The authors are Drs Brethaur and Schaur and Jeffrey Hammel M.S. of the Bariatric and Metabolic Institute of the Cleveland Clinic, Cleveland, Ohio. Thirty-six studies involving 2570 patients who had the VSG procedure were analyzed. Their conclusion was
“From the current evidence, including 36 studies and 2570 patients, LSG is an effective weight loss procedure that can be performed safely as a first stage or primary procedure. From this large volume of case series data, a matched cohort analysis and 2 randomized trials, LSG results in excellent weight loss and co-morbidity reductions that exceeds , or is comparable to, that of other accepted bariatric procedures. The postoperative major complication rates and mortality rates have been acceptably low. Long-term data are limited but the 3- and 5- year follow up data have demonstrated the durability of the SG procedure. “
There is now a considerable body of data and studies supporting the safety and effectiveness of the VSG as a primary procedure for weight loss. The June 2009 Supplement to Bariatric Times reporting on the Second International Consensus Summit on Sleeve Gastrectomy (available at www.bariatrictimes.com) includes 10 papers pertaining to the safety and effectiveness of the VSG presented by leading bariatric surgeons. In Reducing Risk in Bariatric Surgery: Rational for Sleeve Gastrectomy [RL2], Dr. Eric J. DeMaria concludes that “A growing body of evidence suggests sleeve gastrectomy may be an appropriate primary bariatric surgical procedure primarily due to low risk and ease of surgical revision when required.” In the paper presented by Drs Jossart and Cirangle, four years of data showed a 68% excess weight loss by VSG patients, a figure not largely different than RNY patients of the same time range. Additionally, at the International Consensus Summits for Sleeve Gastrectomy March 19-21, 2009 [RL 3],this was the response: At the second conference, during the consensus part, the audience responded that there was enough evidence published to support the use of SG as a primary procedure to treat morbid obesity and indicated that it is on par with adjustable gastric banding and Roux-en-Y gastric bypass, with a yes vote at 77%.This is perhaps the strongest contribution to this second consensus conference.
The American Society for Metabolic and Bariatric Surgery (ASMBS) issued an “Updated Position Statement on Sleeve Gastrectomy as a Bariatric Procedure” [RL 4] on November 9, 2009. This statement supported the use of the sleeve gastrectomy procedure as a standalone treatment of morbid obesity:
“Limited intermediate-term (3–5-year) data have been published in peer-reviewed studies demonstrating durable weight loss and improved medical co-morbidities in patients treated for morbid obesity using the [sleeve gastrectomy] SG procedure. The long-term follow-up data at 5 years for high-risk and super-obese patients are limited, in part because some patients undergo a planned second operation (Roux-en-Y gastric bypass or duodenal switch) within 2 years of their SG, either as part of an overall staged treatment strategy or because of weight loss failure or weight regain. Informed consent for SG used as a primary procedure should be consistent with the consent provided for other bariatric procedures and should include the risk of long-term weight gain.”
The ASMBS notes several studies that suggest that due to the fast paced changes occurring in this field, the medical and insurance community should review its statements of denial due to limited supporting evidence of the long-term outcomes of this procedure. Although originally this procedure was not standalone, but rather step one of a two step procedure for the extremely morbidly obese, due to several factors, many of the original participants never underwent stage 2, and maintained weight loss equal to that of other procedures with only the first stage (VSG).
Most importantly, the rates of improvement of secondary conditions such as diabetes, hypertension, hyperlipidemia, and sleep apnea are comparable to those seen in other restrictive only procedure. The rates of complications due to surgery are relatively low and again comparable to other gastric surgeries. The rates of weight loss are higher than that of gastric banding, and comparable to those who received the RNY surgery, both at 1 year and 3 years post-op.”
It appears that the VSG, based upon the information and articles cited above, has been performed on thousands of patients, has been accepted by a consensus of participating members of an international conference devoted to this subject, is widely accepted by the ASMBS, does not require FDA or similar government approval, is in fact supported by at least 36 studies analyzed by highly respected physicians, is as effective as the RNY and more effective than gastric banding in terms of percentage of excess weight loss, has fewer complications than the RNY, has as good or better reduction of co- morbidities as other procedures, and has results that are similar in studies by both United States and foreign physicians. The VSG therefore no longer falls within the definition of investigational procedures excluded from coverage. This can also be concluded as some Insurers are now covering the VGS, such as [RL 5] Aetna, Inc., United Healthcare, and Medicare to name a few. I request coverage be granted for the laparoscopic sleeve gastrectomy procedure. Thank you for your review of this matter. Sincerely, Brenda XXXXXXX Research links: RL 1: http://my.clevelandclinic.org/Documents/Bariatric_Surgery/Systematic_Review_of_Sleeve_2009.pdf RL
2: http://www.nxtbook.com/nxtbooks/matrix/bt_supp0609/index.php?startid=Cover1#/8 RL 3: http://www.ncbi.nlm.nih.gov/pubmed/19632647 -- RL
4: http://www.asmbs.org/Newsite07/resources/Updated_Position_Statement_on_Sleeve_Gastrectomy.pdf RL 5: http://www.facs.org/surgerynews/2010/0510.pdf - Enclosures: Additional Information; Medical News Today – 05 May 2007 “Study Shows Vertical Gastrectomy is Safe, Effective Treatment For Different Types Of Obesity” http://www.medicalnewstoday.com/articles/69889.php Obesity Surgery – 2010 Dec. 3 “Laparoscopic Sleeve Gastrectomy is a Safe and Effective Bariatric Procedure for the Lower BMI (35.0-43.0 mkg/m(2)) Population” Gluck B, Movitz B, Jansma S, Gluck J, Laskowski K. http://www.ncbi.nlm.nih.gov/pubmed/21128003
Here is a copy of my personal appeal letter. "Thank You's" also go out to others on OH, for helping me with this appeal letter. I am posting it here for anyone who should need ideas and information for their appeal letter.