IRE REQUEST

Dec 03, 2010

Date: November 27, 2010   To:                  Humana Insurance Company                         Grievance and Appeal Department                         P.O. Box 14546                         Lexington, KY 40512-4546   From:             Buford Edwards II                         ***************                         ***************   Independent Review Entity Request Reference Number: *************   Dear Sir/Madam,   I have received correspondence dated October 4, 2010 stating that my initial appeal of Humana’s denial of my request for a revision from the laparoscopic banding procedure performed in January 2009 to a duodenal switch submitted on September 21, 2010 has been reviewed. The correspondence has indicated that my requested insurance coverage for this procedure has again been denied. Therefore, I submit this additional correspondence in appeal of this adverse decision and as a request for this claim and all corresponding medical records to be submitted to and Independent Review Entity (IRE) for review and determination. The reasons for this request are as follows:   1.      In the denial letter dated October 4, 2010, the correspondence states that Humana’s Grievance and Appeal Medical Director in conjunction with an external independent reviewer specializing in general surgery and bariatric surgery reviewed the case. The correspondence first states that the Grievance and Appeal Medical Director is a pediatric critical care physician. I submit that although this physician is no doubt a competent and well respected physician, as a critical care pediatric physician, the named physician has not received the necessary training and specialization regarding complex bariatric procedures. All bariatric procedures are very complex, with the revision and duodenal switch procedures being the most complex of all. Without specialization and training specifically in bariatric procedures, a decision as to the medical necessity of the type of procedure being requested, would fall outside this physician’s scope of training and expertise.    Additionally, I submit that Dr. Kim, who Humana states is a physician specializing in general and bariatric surgery, does not appear to be a specialist in the area of bariatric procedures. Although Dr. Kim does perform some bariatric procedures, according to Tuft’s Medical Center’s website, Dr. Kim is “board certified in general surgery” and there is no mention of specific training or specialization in bariatric surgery. Also, in reviewing Tuft’s website, where Dr. Kim’s medical profile can be found, it appears that the only bariatric procedures performed by this facility are the adjustable gastric banding and gastric bypass surgery. There is no mention of the duodenal switch procedure or revision procedures, which are both unique to my case. I question this physician’s ability to make a determination as to medical necessity, when the facility in which she practices medicine does not even perform the requested procedure. Also as a surgeon, she has never performed any sort of medical examination to determine medical necessity and is relying solely on written documentation.    Again, in order to make a qualified decision as to medical necessity with regard to this case, the physician should be both a dedicated bariatric surgeon and also be experienced in both the duodenal switch procedure as well as revision procedures. I submit that my treating surgeon, Dr. Hugh Houston, who recommends both the revision and the duodenal switch procedure, meets these qualifications. Dr. Houston is a vetted bariatric surgeon and specializes in both revisions and the duodenal switch procedure. His practice is dedicated solely to the treatment of obesity.    2.      It appears that the crux of the denial is rooted in documentation of complications of the original bariatric procedure. Initially, there was not significant documentation to this effect. However, since the initial denial there have been the following medical developments with regard to this case:   A.     I had a follow up appointment with my primary care physician, Dr. Christopher Sims in Stanford Kentucky on October 12, 2010. During this visit, Dr. Sims ordered and Upper GI and initially diagnosed me with dyspepsia, due to the pain in my upper left abdominal region as well as GERD. In addition to ordering the Upper GI, Dr. Sims also prescribed me Omeprazole to take daily in an attempt to alleviate some of the symptoms, which has not been effective.      B.     On October 19, 2010 I had an Upper GI with double contrast performed at Haggin Memorial Hospital in Harrodsburg, Kentucky, performed by Dr. Brooks Hicks. The Upper GI report documents the presence of a hiatal hernia as well as “considerable gastroesophageal reflux,” which are both documented complications of adjustable gastric banding procedures.    C.     On November 12, 2010 I had a follow up appointment with Dr. Hugh Houston of Centennial Bariatrics in Nashville, Tennessee.  During this appointment, Dr. Houston performed another Upper GI and examined me under flouro. Also, Dr. Houston ended up removing some fluid from the lap-band in an attempt to relieve some of the abdominal pain, reflux, and vomiting. By doing this, the effectiveness of the lap-band itself has been drastically reduced and the symptoms of the complications have not diminished. Also, Centennial will be again submitting their findings to Humana for approval of the revision procedure originally requested in September 2010.    Based on this information, since October 2010, there have been multiple complications, documented by three separate physicians. These complications area a direct result of the banding procedure performed in January 2009.
  3.       Pertinent facts of this case are as follows:   A.    Prior to the lap-band procedure there was no hiatal hernia. B.     Prior to the lap-band procedure there was no dyspepsia. C.     Prior to the lap-band procedure there was no gastroesophageal reflux. D.    Prior to the lap-band there was no vomiting. E.     Prior to the lap-band there was no abdominal pain. F.      Prior to the lap-band there was no diarrhea.  G.    Since the lap-band there has been a failure of sustained weight loss.  H.    Since the lap-band there has been no resolution of any co-morbidities. I.       Since the lap-band, all non-surgical attempts to relieve the above mentioned complications have been unsuccessful.     Therefore, it is my conclusion that the only way to alleviate these complications of the lap-banding procedure is removal of the band and further bariatric surgical intervention, namely a revision to a duodenal switch. The only way to repair the hiatal hernia is surgery and the only way to alleviate the other complications is to remove the source of the complications, the lap-band itself.  The only course of action, after removal of the lap-band, would be a revision to another bariatric procedure in which the duodenal switch is the most effective and proper course of action for a patient with my BMI.    Finally, I cite Active Health Management’s Medical Management Guidelines “B Section” under the heading “Revisions or Repeat Bariatric Surgery.” The guideline states, “revision or repeat bariatric surgery is considered medically necessary when the patient had originally met clinical indications for Bariatric surgery and now presents with abdominal pain, bleeding, vomiting, nausea, or diarrhea that is documented to be related to the previous surgery and when all the following apply: Confirmed by radiographic and/or endoscopic testing to be related to the previous bariatric surgery. Complications are not the result of patient non-compliance. Symptoms have not been responsive to (documented) conservative treatment approaches. Surgical intervention is indicated to correct or modify the prior surgery.” Based on these guidelines, I submit that the information contained in my medical records from Dr. Christopher Sims, Haggin Memorial Hospital, and Centennial Bariatrics, along with information included in this letter and my original appeal (attached), meets all of these qualifications. It is my request for this revision procedure from lap-band to duodenal switch be approved without further delay.    Again, I thank you for your time and attention to this request. Medical records from my primary care physician, Dr. Christopher Sims can be obtained by contacting his office at ***-***-****. Medical records from Haggin Memorial Hospital can be obtained by contacting medical records at ***_***_**** (Accession: **********, MRN: *******). Medical records from Centennial Bariatrics can be obtained by contacting Dr. Hugh Houston at ***_***_****. Further, I can be contacted with any inquiries at ***_***_****.   Thank you,         Buford Edwards II

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