bufedwards
Insurance Appeal Letter
Sep 21, 2010
The formatting is off but below is the text of the appeal letter I sent today....
To: Humana Insurance Company
Grievance/Appeal Unit
PO Box 14546
Lexington, KY 40512-4546
From: Buford Edwards II
Date: September 21, 2010
Dear Sir/Madam,
I have received correspondence dated September 16, 2010 stating that my request for revisional bariatric surgery has been denied by your contracted vendor, Active Health Management. Therefore, I submit this letter as an APPEAL to this adverse decision, which could result in grave consequences to my overall health. Pertinent details of this denial letter are as follows:
DETAILS
Patient Name: Buford Edwards
Patient ID:
DOB:
Reference ID:
Provider: Dr. Hugh Houston
Facility: Centennial Center for the Treatment of Obesity
Service Date: 9/14/2010
Service: Hospitalization
Decision: Denial 1 Procedure
Date of Review Decision: 9/15/2010
Reason for Non Approval: The requested revision of a lap band to a Duodenal Switch is denied because documentation does not indicate (1) that complications requiring revision (e.g. vomiting, bleeding, diarrhea, intractable pain) have arisen as a result of the member’s first bariatric procedure (2) that the member has had a recent evaluation indicating there are no behavioral contraindications to the procedure. The ActiveHealth Management AC-AHM39BAR BARIATRIC SURGERY guideline was used to make this determination.
DECSION:
-The above service has been determined to be not medically necessary for your condition based on clinical information submitted A second review for the requested services may be performed if additional information is provided. Your doctor has been notified. You may contact your treating physician to discuss further options of care.
-Your health benefit plan may cover alternative benefits. For questions about your benefits please call Humana at 1-877-KY-SPIRIT (597-7474).
Additionally, I have contacted Humana at the above listed phone number and spoke with Denissa, one of your customer service representatives. She was very professional and polite, and offered what assistance she could with the matter. However, she informed me that there were no specific details regarding bariatric surgery in the Humana policy, other than the information provided in the Summary Plan Description, which states that Bariatric surgery is a covered procedure under Morbid Obesity services. In fact, the plan states that this is “payable the same as any other sickness.” Also under the exclusions section, the plan states that treatment for obesity is not covered “unless qualified as morbid obesity and medically necessary” as well as “unless qualified as morbid obesity and medically necessary for the purpose of treating sickness or bodily injury caused by, complicated by, or exacerbated by the obesity.”
Also, under the definitions section of the plan it states the following:
Morbid obesity (clinically severe obesity) means a body mass index (BMI) as determined by a qualified practitioner as of the date of service of:
40 kilograms or greater per meter squared (kg/m2)
35 kilograms or greater per meter squared (kg/m2) with an associated comorbid condition such as hypertension, type II diabetes, life-threatening cardiopulmonary conditions; or joint disease that is treatable, if not for the obesity.
Finally, I have also contacted Active Health Management to request specific information regarding guideline “AC-AHM39BAR Bariatric Surgery” as well the “nationally accepted guidelines [that] were used by our doctors and nurses to make this decision,” that is also referenced in the denial letter. I have been assigned a case manager named Pam Appler and am awaiting a return phone call from Ms. Appler.
Regarding the “reason for non approval” section of the denial letter, the correspondence states that “complications requiring revision (e.g. vomiting, bleeding, diarrhea, intractable pain) have arisen as a result of the member’s first bariatric procedure.” In fact, this has not been the case. In the (18) months since having the adjustable gastric banding procedure, there have been many complications and I have made numerous complaints to Bluegrass Bariatrics in Lexington, Kentucky regarding food being “stuck” (at least one meal per day, 4 to 5 days a week) and vomiting episodes. The response I have received is “chew more” and “that is just part of having a Lap-Band.” Most days, I am unable to eat solid foods for several hours, until my band “loosens up” as Bluegrass Bariatrics puts it.
Also, from about six months post-op until now, I have suffered from chronic diarrhea (3 to 5 days a week, every week) which I have attempted to treat myself with products such as Immodium and Pepto-Bismol. In fact, I have had very few normal bowel movement over the past (18) months. Another complication that has begun to arise, within the last three months has been an onset of GERD, which I have been unable to resolve with over the counter acid reducing medications. Additionally, I have also suffered from chronic pain in my upper left abdomen for several months, which at times becomes very intense after eating a meal. This, I was hoping to receive a definitive diagnosis for, with through my pre-operative testing, but it is believed that I have developed a hiatal hernia, which is also a documented complication of adjustable gastric banding.
Finally, the most disturbing complication I have had from adjustable gastric banding has been its overall ineffectiveness as a tool for weight loss and concurrent resolution of comorbid conditions due to morbid obesity. When entering the bariatric program with Bluegrass Bariatrics, I had a starting weight of 518.5lbs and a BMI of 86.27 and the last weigh-in prior to surgery my weight was 491.0lbs and corresponding BMI was 81.78. Initially, through the liquid diet and beginning stages of the post-operative lifestyle, the gastric banding procedure seemed to be somewhat effective. Between January and June 2009, my weight did reduce from 491.0lbs to 425.5lbs with a BMI of 70.3. However, since June 2009, my weight has begun to climb, which is consistent with research regarding the gastric banding procedure, especially in those with very high BMI ranges. However, Bluegrass Bariatrics was unwilling to accept the fact that the banding procedure was a failure and continued to try different methods to assist me in losing weight. I also, continued to comply with their every request and continue to comply with the original post-operative diet they placed me under. My last appointment with Bluegrass Bariatrics was in September 2009, in which my weight was 443.5lbs with a corresponding BMI of 73.9. During this appointment I was subjected to a BMR test and told to eat between 2500 and 3000 calories a day to achieve some weight loss. Since this time, Bluegrass Bariatrics has not scheduled any follow up. However, I began to diligently research all the bariatric procedures currently offered (gastric banding, gastric sleeve, gastric bypass, and duodenal switch) and through my research have concluded that (1) Bluegrass Bariatrics suggested and performed an ineffective and erroneous procedure for an individual with my starting weight and BMI, which has resulted in multiple complications and ultimately failure of the procedure. Also, (2) the duodenal switch procedure is the only procedure that is effective in treating morbid obesity in individuals with a very high BMI (over 50). This is even further evidenced by the fact that my BMI has never been below 70, throughout this process. Research also confirms the conclusion that this procedure was a failure. Success for bariatric procedures is measured by patients losing at least 50% of their excess weight and maintaining that loss for a period of five years. I lost a total of 26% of my excess weight initially, and after only (18) months, my overall weight loss has been approximately 3%.
Research documenting the prevalence of adjustable gastric banding failure is as follows:
-Allergan, the manufacturer of the Lap Band, published the following as part of their Patient Safety Information. “In the United States clinical study, with 3-year follow-up reported, 88% of the 299 patients had one or more adverse events, ranging from mild, moderate, to severe. Nausea and vomiting (51%), gastroesophageal reflux (regurgitation) (34%), band slippage/pouch dilatation (24%) and stoma obstruction (stomach-band outlet blockage) (14%) were the most common post-operative complications. In the study, 25% of the patients had their band systems removed, two-thirds of which were following adverse events.”
-Published in the journal Obesity Surgery in 2008, the study Long-Term Results of Bariatric Restrictive Procedures: A Prospective Study lap band failure rates were documented at 54% with the most frequent complications being pouch dilatation (21%) and anterior slippage (17%). 44% of the patients required repair or revision.
-In the study Analysis of poor outcomes after laparoscopic adjustable gastric banding published in June of 2010 by George Washington University, the authors indicate a high complication rate for gastric banding procedures including reoperation for 16.7% of the patients in the study. The majority of the patients also failed to achieve a 50% excess weight loss.
-In another study that included patients observed over 9 years, Long-Term Results and Complications Following Adjustable Gastric Banding, 52.9% patients had at least one complication requiring reoperation and the band was removed for 28.6%.
-Most significant is a recent study A 10-year experience with laparoscopic gastric banding for morbid obesity: high long-term complication and failure rates. In this study, a group of physicians from Switzerland led by Dr. M. Suter, MD, PD, FACS, examined the long-term complications related to LapBand weight-loss surgery. The study demonstrated that LapBand long-term complications increase over time. Overall, 33.1% of patients had at least one long-term complication related to gastric banding. This study concludes:
“LGB appeared promising during the first few years after its introduction, but results worsen over time, despite improvements in the operative technique and material. Only about 60% of the patients without major complication maintain an acceptable EWL in the long term. Each year adds 3-4% to the major complication rate, which contributes to the total failure rate. With a nearly 40% 5-year failure rate, and a 43% 7-year success rate (EWL >50%), LGB should no longer be considered as the procedure of choice for obesity. Until reliable selection criteria for patients at low risk for long-term complications are developed, other longer lasting procedures should be used.”
-Also, without revision, patients with a failed lap band regain weight and suffer ongoing morbid obesity. In the study weight loss and quality of life after gastric band removal or deflation, nearly 88% of patients whose lap bands were removed regained weight. This study, like several others, indicate that revision is necessary to treat morbid obesity over the patient’s lifetime.
-Replacement of the lap band is contraindicated in patients with a slip and/or esophageal dilation. As noted in many of the studies cited above, slips and esophageal dilation are a relatively common complicate for lap band surgery patients – as high as 20% of all patients will suffer from one or the other or both. Because esophageal dilation is not treatable and because it is a progressive disorder, reinstruction of a lap band is contraindicated. The only treatment for lap band slips and esophageal dilation is removal or de-inflation of the lap band which, as shown in item 2 above, results in a return to morbid obesity in 88% of patients studied.
-I have found that the DS has the best cure rate, for hypertension, high cholesterol, and the lowest failure rate after 10 and 15 years with the highest amount of weight loss. This is without the complications of the Roux-en-Y gastric bypass which may include dumping, vomiting, weight regain, and stomach ulcers. The Duodenal Switch leaves the stomach fully functional, just smaller. It allows me to use the NSAIDs that I need in order to function with my back and joint problems.
-The Duodenal Switch now has a 20+ year history, and the medical literature contains numerous published long-term studies documenting its safety and efficacy in patients more than 10 years after undergoing the procedure. It is offered by many bariatric surgeons worldwide, further supporting its safety and efficacy for any patient who qualifies for bariatric surgery.
-The Duodenal Switch is endorsed as a standard-of-care procedure for any patient who qualifies for bariatric surgery (and not limited to patients with BMIs over 50) by the American Society of Metabolic and Bariatric Surgeons (ASMBS), American College of Surgeons, American Association of Clinical Endocrinologists, and Medicare, among other organizations. In addition, the DS is now accepted as standard of care by most insurance companies.
Therefore, based on this research, I then began to contact bariatric programs that perform the duodenal switch, utilizing Humana’s doctor search function and found Dr. Hugh Houston and the Centennial Center for the Treatment of Obesity, which is in-network for my current insurance coverage. I also researched Dr. Houston a great deal and found that he is both a renowned duodenal switch surgeon as well as an expert in the field of revision bariatric surgery. Therefore, I contacted Centennial and began the process of once again attempting to treat my morbid obesity. On September 13, 2010, I consulted with Dr. Houston, at which time the reality of the failure of the gastric banding was apparent. My weight during this consult was 508.0lbs with a corresponding BMI of 84.5, meaning that I had gained back all but 10.0lbs of my original weight when I entered Bluegrass Bariatrics program. Also, Dr. Houston questioned many of Bluegrass Bariatric’s procedures, including their choice to perform a gastric banding procedure on an individual with a BMI such as mine. In fact, Dr. Houston suggested that the only procedure he would recommend for me, or another in my situation, would be the duodenal switch procedure.
Given these numerous complications and issues that I have had with the adjustable gastric band, I have concluded that Active Health Management’s decision that a revisional procedure is not medically necessary to be in error. According to the National Institute of Health morbid obesity is a medical disease, just as any other commonly accepted medical disease. In fact the Americans with Disability Act considers this disease a disability and those who suffer from morbid obesity to be a protected class, the same as race, age, and gender. The standard of care set for the treatment of morbid obesity is surgical intervention. Research shows that the only effective treatment for morbid obesity is surgical intervention. Also research shows that the only effective surgical intervention for an individual with a very high BMI is a duodenal switch procedure. To perform a gastric banding procedure on an individual within this BMI range is an error in practice by a physician.
Also regarding medical necessity, I have also met all requirements set forth by Humana to determine that continued treatment for morbid obesity is a medical necessity. Humana states that morbid obesity is having a BMI of 40 or of 35 with comorbidities. Throughout the course of my treatment my BMI has never been below 70 (almost double the standard for morbid obesity) and is currently 84.5 (more than double the standard for morbid obesity) and I have only maintained an excess weight loss of 2%. Also, I have suffered and continue to suffer from several comorbidities (varicose veins, knee pain, chronic back pain, sleep disorder-not apnea, sleep apnea, fatigue, shortness of breath, GERD, peripheral edema, veinous insufficiency, hernia, planters fasciitis, and pain when walking or standing), which will only add to the overall cost of the treatment of my obesity. In fact, it is well documented that the overall cost of the treatment of obesity is far greater if left untreated, than even the most expensive surgical procedure. In fact, in an article in the March 9, 1998, issue of the Archives of Internal Medicine 17,118 members of the Kaiser Permenente Medical Care Program were studied to determine the association between body fatness and health care costs. The results showed that patients with BMIs greater than 30 had a 2.4 times greater risk for increased inpatient and outpatient costs than patients with BMIs under 30. Indirect costs: Americans spend an additional $33 billion dollars annually on weight-reduction products and services, including diet foods, products, and programs. Most of these expenditures, as is evidenced in this case, are not effective.
Also of grave concern are several abnormalities in pulmonary function in obese individuals. At one extreme are patients with so-called Pickwickian syndrome, or the obesity-hypoventilation syndrome, which is characterized by somnolence and hypoventilation; it eventually leads to corpulmonale. In patients who are less obese, there is a fairly uniform decrease in expiratory reserve volume and a tendency to reduction in all lung volumes. A low maximum rate of voluntary ventilation and venous admixture is also present. As an individual becomes more obese, the muscular work required for ventilation increases. In addition, respiratory muscles may not function normally in obese individuals.
Other issues I face are a significant family history of morbid obesity as well as heart disease and type II diabetes, which research has indicated, I will also begin to suffer the effects of if my obesity is not resolved. In fact, in my original referral asking for insurance approval for bariatric surgery, the treating physician writes, “As we have reviewed all options, the patient, likewise has determined that bariatric surgery is the best option for his complex[ity] of diseases. The patient’s diseases are progressive and life threatening; we would ask for an efficient and timely review of this case. To require any further ‘medical’ or ‘dietary’ treatment or documentation would be medically unsound and dangerous. As listed above, the morbidly obese patient is statistically higher risk of developing or exacerbating life-threatening diseases. Medical treatment is well known to be ineffective, with ‘almost all persons who lose weight will regain it within five years’. Denial of coverage may cause serious injury, or permanent disability, through lack of access to necessary surgical treatment. Morbid obesity has been held by the federal appeals court to be a disability, under the Americans with Disabilities Act. For an employee, discrimination against such disability, with respect to provision of contracted medical benefits, may violate the insured civil rights under the legislation and may subject the employer or carrier to additional risk.”
Based on this referral, Humana approved an initial bariatric procedure, deeming it medically necessary. Since that time, none of the life threatening conditions mentioned have been resolved or even improved. In fact, my overall health has continued to deteriorate, thus deeming that further and more aggressive surgical intervention continues to be medically necessary. Given the continuum of care for medical treatment, it is not uncommon for conditions to be treated by multiple surgical interventions, when initial treatment fails to correct the medical issue. An example of this would be a patient with heart disease. Patients who suffer from blockages and heart attack typically have multiple “stint” placements and when those are ineffective, the end result is a more invasive open heart procedure. This is done in an attempt to preserve the patients’ life as well as their quality of life. The treatment of morbid obesity is no different. When initial surgical intervention has failed, the course of action is more invasive surgical intervention to both preserve the patient’s life as well as improve their quality of life. Humana’s own policy states that morbid obesity is to be treated as any other sickness, thus acknowledging Humana’s acceptance of morbid obesity as a medical condition that should be treated by the most effective means possible, which is surgical intervention.
Finally, the second reason for denial of this medically necessary procedure, listed in the non approval section of the letter from Active Health states, “that the member has had a recent evaluation indicating there are no behavioral contradictions to the procedure.” This, in fact, is also inaccurate. Prior to my initial bariatric procedure a psychological evaluation was performed by Dr. Perry E. Brown Ph.D., Kentucky License No. 498, which has been provided to Humana. Dr. Brown’s conclusions and recommendations state, “this patient appears to be a generally emotionally stable man who presents with no significant psychological problems that are likely to interfere with his post-surgical adjustment. My impression is that he is an appropriate candidate who should be able to handle the stresses and demands associated with the significant changes that will occur after surgery.”
Also, I personally hold an MSSW from the University of Louisville and understand first-hand the issues surrounding the “stigma” of obesity. In fact, research has indicated that the main reason that those who undergo bariatric surgery should be considered for a psychological evaluation should be to rule out clinical depression, not to determine medical necessity. Depression has been previously ruled out and my mental health status has not declined since my original evalution. The fact that insurance companies even require psychological evaluations for determination of whether a person is fit for a surgical procedure to treat a physical illness is contradictory to the insurance company’s own guidelines. Again, I turn to the fact that Humana has defined morbid obesity as a medical condition, not a mental health condition, and determined that it should be treated as any other sickness. With that said, Humana does not require psychological evaluations for the treatment of any other medical condition (i.e. heart disease, type II diabetes, etc . . . ). To place this requirement on bariatric patients is not cost effective and also places morbidly obese patients in a unique category, which could be viewed as discrimination in violation of the Americans with Disabilities Act. However, if Humana and Active Health Management insist, and require me to be re-evaluated, I will be happy to do so, so long as it is a covered expense under my policy. The preservation of my health and life is worth the removal of any obstacles that would prevent further surgical intervention.
In conclusion, I would like to thank Humana for the timeliness of my notification as well as the opportunity to appeal this adverse decision. Further, due to my continual deteriorating medical condition, I would also request that this review be EXPEDITED. Any further delay could further exasperate the complications I am currently experiencing as well as put my overall health and life in jeopardy. Again, thank you for your consideration of my requests. I can be contacted at the above number for any questions.
Sincerely,
Buford Edwards II
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