well i never said i could type

Apr 08, 2010

Just wanted to correct my last post. I am actually down 48 lbs since surgery and 69 pounds total. I am such a poor typist i typed in the wrong number in my last post. I weigh every day and cherish each half pound lost and want credit for it. My surgeon's post op instructions say to weigh only once a week and while i respect the reasons for that, I find i do better if i weigh every morning first thing. Only once per day however. It reminds me each day that i need to take responsibility for what I eat and do. Its part of my routine like morining coffee with benefiber in it, keeping my food journal, taking the actigal and vitamins and other stuff, getting in some protein early in the day so i don't have a  late day deficit etc. Having a healthier routine is important to me since my obesity was in part due to an unhealthy routine of poor eating habits and sedentary life style. And of course a dose of fat genes. Most of my family looks like the Khruschevs. (remember them).

Also find it helps to have little mini victories along the way. The most recent was buying pants without an X in the size. plain old large. Yeah they are stretchy knit so i don't know what a real size would be but don't care.  also ditched the blood pressure med and the potassium supplements that went with it. less pills! yay. and only 1 and 1/2 more months of actigal and another pill bites the dust.

And another big one is I am about 3 lbs from being merely overweight and no longer obese. That will be a fun one. bmi below 30.

Stopped in for  a quick hello to the shrink who did my psych evaluation before surgery. He seemed pleased and wanted to know how it changed my life. Had lots to say there. I could be a salesperson for the vsg.

really appeciate the help I get here on OH. I check it in the morning and in the evening and value the insights i get. Helped me a great deal with the decisions i have made and in understanding this whole process. Nothing like communication with others on the journey to learn the way. Hope I can give back a little to those who have given me a lot. D
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4 and 1/2 months out

Apr 06, 2010

April  6, 2010

Things are going well and i am down 45.5 lbs since surgery and 68.5 total. Wish I could lose a little faster as its about 5 lbs a month but its easy enough to do so I'll take it.

Many of you want a copy of my appeal letter and I am happy to share it. I have emailed it about a zillion times to lots of people so i decided to go ahead and post it below. Remeber that this is an Independent Medical Review to the state insurance dept. in Cal. Other states may have other procedures. Also, you have to get denied on appeal to insurance co before going to IMR. Be sure to write your own medical issues and update the research. I think the ASMBS has now issued a statement supportingvsg which didn't exist when i did my appeal. I have to say that BC immediately acknowledged that they lost and did pay everything. So it was worth doing. Letter appears below. I removed all personal information. Remember to send everything by mail with a tracking receipt so you know when its received and cc it to your insurance company. I sent in the letter plus a couple of attachments but i think the bulk of my medical records were sent in by my insurer plus my surgeon at the request of the state.

State has a nice web site on how to do this and nice people who you can call and they will talk to you and be helpful. Other states - just call the dept of insurance and see what they have. be sure to read your policy on appeal procedures and definiition of investigational. they can all be different. Good luck to all of you.

D




October 5, 2009

 

California Department of Insurance

Claims Services Bureau

300 South Spring Street, South Tower

Los Angeles, CA 90013

 

Re:  File Number  xxxxxxxxx;     Application for Independent Medical Review by  xxxxxxxxx  for denial of approval for vertical sleeve gastrectomy by Anthem Blue Cross;  Anthem  Group  xxx    reference xxxxxx.

 

Dear California Claims Service Bureau;

 

            Please consider this letter as a request for Independent Medical Review

of the denial of authorization for a vertical sleeve gastrectomy “VSG” by my insurance company Anthem Blue Cross. I requested approval for this  treatment for morbid obesity. Anthem denied permission in a letter dated    xxxxx, 2009. I appealed the denial by letter dated  xxxxx, 2009 and received by Anthem xxxxxx   2009. Anthem has now further denied my appeal by letter dated xxxxxxxxx  2009 reference number xxxxxxxx, which they faxed to me on xxxx, 2009. A copy of this letter is attached. The appeal was apparently reviewed by a general surgeon and an ER physician and not by bariatric surgeons.  The only stated reason for denial is that VSG is investigational and that “current medical studies do not show that this service improves health outcomes, is as good as or better than standard alternatives, or shows improvement outside the research setting”.  The recent medical literature and studies I furnished were not addressed nor were my specific medical reasons for not being a suitable candidate for alternative procedures. . I respectfully disagree with Anthem’s conclusion and request that the decision be reversed and the VSG be authorized immediately. I also request that this review be made by one or more bariatric surgeons as I do not believe others are qualified to make this review.

 

                                            I.    PATIENT BACKGROUND

 

            My name is   xxxx   and I am insured under the above group plan. Prior to the effective date of the above plan, I have been insured under one Blue Cross plan or another for at least 20 years.

 

            I am now 58 years old.  I am xxx   tall and at the time I sought approval for this surgery I weighed  xxxx lbs for a BMI of 42.4, well into the morbidly obese category. I have been overweight to one degree or another since I was a young child and was advised by my pediatrician to diet at age 10.  I have made numerous efforts at weight loss throughout my teenage years and adult life. I have had annual physicals and other regular medical care throughout my life with weight loss by traditional dieting being repeatedly recommended.  I dieted frequently as a teenager and young adult. Numerous times I have lost 40 pounds or more but eventually the weight returns and then some. Weight loss programs I tried include “Willpower for Weight Control” sponsored by   xxxxx  Hospital of xxxxx, traditional calorie counting on quite a few occasions, the Atkins diet, use of physician prescribed Phen-Fen which had to be discontinued due to elevation in blood pressure, long term gym membership, lap swimming, weight training, water aerobics,  walking programs, liposuction, the Scarsdale Diet, various buddy-system diets and individual and group therapy with a licensed therapist. In all cases I lost weight but each time the weight crept back, usually with a little more. Eventually I realized that traditional dieting seemed to actually cause weight gain due to increased hunger that seems to occur after significant weight loss. I believe science is only now beginning to understand the reasons for this phenomenon which is consistently reported by clinically obese people. Studies also show that genetics plays a larger role than once thought and there are other morbidly obese people in my family as well as slim people.

 

My co-morbidities include high blood pressure, high cholesterol and back, hip and foot pain. I take hydrochlorothiazide for high blood pressure which is effective. I took statin drugs for high cholesterol for a number of years but had to discontinue them due to significant muscle pain and extreme fatigue. I have a family history of diabetes and of breast and uterine cancer as well as strokes, heart disease and severe arthritis. I take ibuprofen almost daily for back pain and for pain in my hands. I work with my hands and they are often painful at the end of the day. I have Dupuytren’s Contracture (a genetic disorder causing excess scarring of the fascia tissue in the hands resulting in nodules, cords and curling of the fingers to the point of uselessness). I have had several surgeries on my left hand and now have a nodule in my right hand which will probably require treatment. I take ibuprofen for this discomfort as well. Dupuytren’s is progressive and I will likely require further surgery though there are new less invasive treatments becoming available.  I was recently diagnosed with sclerosis of the spine after a routine bone density scan. I also have acid reflux GERD and take Prilosec once or twice daily. I also have a small hiatal hernia discovered during a scope procedure for the GERD. I am advised by my bariatric surgeon that the hiatal hernia can be easily repaired during VSG surgery. I take  xxxx  and  xxxxx  for depression and anxiety from which I have suffered for most of my life which I believe is to some extent connected to childhood obesity.

 

My excess weight makes everyday activities difficult including housework, shopping, standing, walking significant distances, working and recreation. It effectively makes my world smaller limiting the number of things I can do each day. I have lived with obesity for 50 years and strongly wish to change this aspect of my life. I fear the consequences of my high LDL  cholesterol which can’t be treated with statin drugs and fear development of diabetes though I have thus far avoided it. I was stunned to learn that my weight is in the morbidly obese category but heartened to learn of this newer treatment with fewer side effects and shorter recovery. I have consulted with a leading bariatric surgeon who believes I would do well with the VSG. I have lost 14 pounds in preparation for the surgery and have joined a gym and have been attending regularly for 7 months. I am highly motivated to succeed with VSG and understand that food intake will be significantly limited for the rest of my life and that I must continue to exercise to be successful. I am trying to develop some of those healthier eating habits now in anticipation of surgery.  I had given up on traditional dieting as it always resulted in further weight gain and am pleased to have found the VSG surgical option which appears to be the only tool offering a realistic possibility of lifelong weight control.

 

I believe VSG is the best surgery for me because it offers restriction like the lap-band and the RNY but without the malabsorption of the RNY. The RNY is not an option because I very much need regular doses of ibuprofen for back and hip pain and hand pain and expect to continue to need this. Tylenol is not effective for me.  I have the same concern about the lap band as well as the fact that I have a small hiatal hernia which can be a contraindication for the gastric band. I also understand that as many as 27 percent of lap band patients require band removal and weight loss is often unsatisfactory. Most importantly, the VSG removal of a large portion of the stomach removes many of the cells that produce the hormone ghrelin which is known to cause hunger and appetite. The RNY and lap band don’t have this advantage.  At age 58  I am concerned about the side effects of the RNY and do not want to spend 6 or more months with dumping syndrome and feeling rotten. I also worry about the ability to take and absorb other medications I might need in the future as I age. The VSG appears to offer the fastest recovery, weight loss similar to the RNY and the least amount of side effects. One recent publication, “The Best Bariatric Operation  for Older   Patients “ by Drs Lee, Cirangle, Taller, Feng and Jossart, 2005, concludes that “These data suggest that the best bariatric operation for older patients may be the laparoscopic VG because it achieves the greatest weight loss with the shortest operative time and the fewest complications”.

 

I have investigated this procedure very thoroughly including attending support groups and talking with others who have had it. I have completed most of the preoperative testing and strongly believe this is the best procedure for my circumstances

 

     II. THE VSG SHOULD NO LONGER BE CONSIDERED INVESTIGATIONAL

 

The only stated reason for denying approval for the VSG is that it is investigational and …” current available medical studies do not show that this service improves health outcomes, is as good as or better than standard alternatives, or shows improvement outside the research setting”.  It is respectfully submitted that this conclusion is incorrect. The conclusion ignores the 36 studies now available on the effectiveness of VSG which indicate that excess weight loss is similar to the RNY and that complications from surgery are actually lower than RNY.  It also ignores the fact that the VSG is now widely performed and is routine for many bariatric surgeons and has long been performed outside the research setting.

 

Anthem’s policy on Surgery for Clinically Severe Obesity is set forth in a document with an effective date of April 22, 2009. This document reviews the various forms of bariatric surgery and explains when weight loss surgery is considered medically necessary. VSG is excluded from ever being medically necessary because it is designated as investigational and that “…there is insufficient convincing evidence in the peer reviewed medical literature, in terms of safety, to support the use of …sleeve gastrectomy…other than biliopancreatic bypass with duodenal switch, in individuals with clinically severe obesity.”. Nevertheless, the lap band and Realize band procedures are approved as medically necessary in this same document based upon what appears to be two three year studies involving 219 and 352 patients respectively.

 

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, 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.

 

Most significantly, in Debates and Consensus: a Summary by Dr. Michael Gagner,   important questions concerning the VSG were debated and conclusions reached by the 400 conference participants. Question 6 was as follows:

 

“Question 6: In your opinion, is there currently enough published data to support the sleeve gastrectomy as a primary procedure to treat morbid obesity on par with adjustable gastric banding and Roux-en-Y gastric bypass? 

Several groups presented cohorts of patients with follow-up periods of 4 to 8 years the day before. Jossart and colleagues in San Francisco presented eight years’ experience including 1,200 cases, whereas at more than four years, weight loss resulted in a similar curve to gastric bypass. At higher BMI (greater than 55kg/m2) a plateau of nearly 40kg/m2 demanded a second stage, but below a BMI of 55, the operation was terrific. Schauer and colleagues assessed the literature from 35 reports, studied more than 3,000 published sleeve gastrectomy cases, and found an extremely low mortality rate (near 0.12%). Results have shown excellent weight loss and co morbidity reduction that is comparable to or exceeds other bariatric operations and that the sleeve gastrectomy is safe and efficacious. Himpens of Belgium analyzed his patients from 2001 through 2002(sic) to attain six-year follow-up. Sixty-five percent of 46 patients were considered a “success” (%EWL greater than 50 ) at two years. At six years the success rate was maintained at 59 percent. Weiner from Frankfurt and MacMahon of Leeds, who started in 2000, also had similar results.  *** Certainly, the audience thought there was enough evidence published to support the sleeve gastrectomy as a primary procedure to treat morbid obesity on par with adjustable gastric banding and Roux-en-Y gastric bypass with a yes vote of 77 percent. This is perhaps the strongest contribution to this second consensus conference.”

 

A review article entitled “Systematic Review of Sleeve Gastrectomy as Staging and Primary Bariatric Procedure” 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. “

 

To date ten thousand patients have had the VSG surgery with good success. Many are going to Mexico or other foreign countries because their insurers refuse to pay for the VSG even though it is less expensive than the RNY procedure, the so called “gold standard” of weight loss surgery which takes several hours and requires a hospital stay of 3 or 4 days. The VSG can be completed in one hour by a skilled surgeon and most patients stay only one night in the hospital. While there is certainly follow up care, the repeated fill and unfill procedures required by gastric banding are unneeded for the VSG. Nutritional supplements are much less of a problem than with the RNY. Many insurance companies are recognizing the value and cost effectiveness of the VSG  and  have approved the VSG for at least some patients, including BSBC Federal, BC Anthem of California PPO, Triwest Tricare Prime, United Healthcare, the Veterans Administration, Aetna, Blue Care Network HMO, Healthnet, Anthem BC of Connecticut, Definity Health/United Healthcare, Kaiser Permanante, Aetna Choice PPO, Empire Blue Cross Anthem, and UHC. I have recently been told that United will now start approving VSG on a regular basis as does Blue Cross Federal.

 

The California Department of Insurance has recognized that VSG is widely accepted by the American Society for Metabolic and Bariatric Surgery as a standard procedure at medical centers for excellence. In Decision #EI09-9645 the physician reviewers reversed the health plan’s denial of the patient’s VSG request and concluded that VSG was the most appropriate option for the patient. The same conclusion was also reached in EI06-5882 though the patient had significantly more co-morbidities. That decision noted the important fact that the VSG is nothing more than the first part of the duodenal switch operation which includes the second step of intestinal modification and as such, the VSG portion has been performed for many  years as part of the DS procedure. Some patients have the VSG first as part of a two stage procedure and find that they do not need the second stage. Thus, the VSG is not as new and investigational as Anthem’s conclusions seem to imply. Anthem does cover the DS procedure which includes the VSG as one part.

 

According to an article published in the Detroit Free Press on August 17, 2009, Blue Cross Blue Shield of Michigan, in conjunction with the University of Michigan, has been compiling a large detailed data base on bariatric surgery in order to improve surgical outcomes and provide cost savings. In three years of data collection, it appears that the VSG now accounts for as much as 12% of all bariatric procedures. This percentage indicates that the procedure is far beyond investigational status. This data base indicates that 10,000 VSG procedures are known to have been performed.

 

My Anthem group policy excludes investigational procedures and defines that term as procedures:

 

  “ 1) that have progressed to limited use on humans, but which are not generally accepted as proven and effective procedures within the organized medical community; or 2) that do not have final approval from the appropriate governmental regulatory body; or 3) that are not supported by scientific evidence which permits conclusions concerning the effect of the service, drug or device on health outcomes; or 4) that do not improve the health outcome of the patient treated; or 5) that are not as beneficial as any established alternative; or 6) whose results outside the investigational setting cannot be demonstrated or duplicated; or 7) that are not generally approved or used by Physicians in the medical community. “ Anthem Blue Cross Life and Health Insurance Company Certificate page xxxxxxx).

 

It appears that the VSG, based upon the 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. The conclusions stated in the previously cited Anthem  Policy on Surgery for Clinically Severe Obesity are simply no longer correct and that policy should be updated to include VSG coverage or disregarded.

 

With the VSG patients lose about 68% of excess weight and lower BMI patients like myself often do much better. Weight loss will most certainly help my back and hip pain and improve ability to exercise. High cholesterol is corrected in about 76 percent of WLS cases and I am hoping for this result since I cannot take statin drugs. It is therefore highly likely that my health will be improved by this procedure and I respectfully ask for your reversal of Anthem’s denial of my appeal.

 

Thank you for your review of this matter. I greatly appreciate the fact that the state of California has a procedure to help insured patients who find themselves in disagreement with their insurance companies.  I can be reached as indicated below if further information is needed.

 

 

 

 




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14 weeks out

Mar 08, 2010

Never said I would be a frequent blogger. just not in my nature. But I thought it was time for an update at least for my own benefit if no one else reads this. As of today i am down 45 lbs from surgery and 62 total. That leaves 55 to go to preferred goal and 35 to the higher end goal. Really want to get to the lower goal due to the occasional rebound that some folks have. Now that i am passed those early days of gagging on three protein drinks a day and wondering if my tummy would ever just be quiet, I am feeling great and doing well. As mentioned on previous post, surgery was a breeze and recovery quick. I am back to the gym twice a week. don't exercise as much as I should but then again i am much more active - able to do more things in a day. Its still hard to get the protein in sometimes and once in a while i have a bad day and only get 50 or so but i just decided not to worry too much and do better the next day. I used to sit around at 10 pm feeling stuffed and wondering how i was going to get down 15 more protein grams but now i just go "oh well" and do better next time. I have found mixing a blob of greek yogurt into protein drinks cuts the sweetness. also, a liberal sprinkle of cinnamon disguises the icky smell some of them have. Mostly though i drink costco premier as they are ready made and you don't have to smell the powder in the tub which grosses me out.

So now its just a matter of gutting it out through the next six months and getting the rest of the weight off. But i am about halfway there and feel so much better. ditched the BP medicine and that felt good. looking forwardto getting rid of more pills, including actigal.

thats about it/
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6 weeks after

Jan 09, 2010

A lot has happened since my last blog post. My first appeal to Blue Cross was denied so I immediately filed an appeal called an Independent Medical Review with the state of California Department of Insurance. The department has a web site that tells you what to do and has forms. Even BC sent the info on it with their denial letter. So I filed the appeal. I concentrated my effort on the fact that the only reason for denial was that they consider it investigational. I cited all kinds of studies and surveys, much of which I found through OH, to argue that the procedure no longer comes withing my policy definition of investigational. I also gave my medical history with obecity and argued reasons why the RNY or band would not be suitable for me. The matter was reviewed by 3 surgeons, one of whom was a barriatric surgeon and one was a surgeon of the ailementary tract and the other was just some surgeon. Anyway, I won by a vote of 2 to 1. Blue Cross immediately retracted their denial and paid for my surgery which was on November 17. I was lucky my surgeons had a cancelation because I was going to have to wait until december 15. I had to go to Good Samaritan in San Jose because that is a Blue Cross approved center. Would have preferred California Pacific but I have to say GS was very good and I have no complaints about them. I think I got the approval a few days into november so it was a 10 day whirlwind to get ready, have my husband get time off, find a place to board the dogs, make hotel reservations, get records and tests, and get everything whipped into shape. But I did it and am proud.

I was a little worried about the surgery in a strange hospital (to me) and the fact I am 58 I was afraid it would be hard on me and a rough time. Boy was I wrong.  The surgery was a breeze. Minimal pain, up and around in a few hours, able to use potty, only a 5 minute nausea bout quickly fixed with a shot, zilch pain after the toredal shots, good nursing care. The hardest part was my husband (night blind) trying to find pharmacy after dark to get drugs i needed to go home. We live 300 miles away so after I was dismissed , we stayed the night in a hotel and left for home next morning. I was groggy due to anti nausea drugs and pain killer but totally comfortable. Once I got home and got a really good nights sleep I was up and wandering around the house looking for something to do. While there was an occasional rough moment (read:constipation) that was about the worst of it plus i don't really like my protein drinks.

I really credit my easy surgery and recovery to the skill and experience of my surgeon Dr. Paul Cirangle. He and Dr.J ossart really know what they are doing. I had read quite a few of their scientific publications describing how they refined the technique and things they do for patient comfort. I also credit it to the fact that I did prepare by beginning an exercise program a few months earlier and losing 18 lbs so i was a little stronger. DR. said I had a pretty bad fatty liver even with the weight loss so its really good i have done this. Fortunately, liver biopsy indicated nothing more than fat and no liver damage.

So I have lost about 30 lbs in 6 weeks which i am happy with though other people seem to lose weight faster. I have always been a slow loser and probably willl be here to. I have started back to Curves and probably need to step up exercise overall. Have found it pretty easy to stay within the diet rules as far as calories and carbs go. Some days I can't get quite all the protein but keep trying. I can eat eggs and dairy and have so far found no food intolerances. Feel lucky there.

So now what is left to do is just lose the [email protected]^#%#(@&#&&#  weight. I am confidant I can keep to the program and just hope my body responds. Just dropped below the 200 mark for the first time in I don't know how many years and it feels great. clothes are getting baggy but I won't get many new ones until another 10-20 lbs. I am not much of a clothes nut since i work as a ceramic artist and get really messy all the time.

Well thats about it. I wish everyone else an experience as easy and positive as mine.
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Starting out

Oct 04, 2009

Well I have never written a blog before but I have been reading and occasonally posting on this site for several months so I thought it was time to write something about why I am here. I've been overweight to one degree or another for nearly my entire life going back to early childhood. A few times I managed to diet down to a nearly normal weight but , well, you know that never lasts. I started thinking seriously about wls after watching Big Medicine and looking at the LapSF web site. I was horrified to find that I had a BMI of 42, officially morbidly obese.

I went to a LapSF program and was impressed and decided that if I had surgery, they were the ones to do it. But it took me several months to really make the decision. Then I had a couple of trips scheduled and bla bla bla so I couldn't get serious about this until mid august. Have now had all the preop tests except one that my internist wants (next week) and blood work. I decided to try to get Blue Cross to pay for the VSG because I think its really close to getting off the investigational status. I appealled the first denial and am told that appeal was also denied though I haven't gotten that letter yet. I plan to seek an independent medical review with the state of California as they have reversed some plans and I think its worth a shot and will only delay a few more weeks. So I am really ready and anxious to get on with this.

Meanwhile I joined Curves and have tried to eat a little more reasonably and have lost 14 of the 15 lbs that Dr. Cirangle wanted me to lose. Now I am scared I will gain it back! Anyway, hope to get surgery in early November. One advantage is that it will get me out of cooking Thanksgiving Dinner which I have come to hate doing. Too much work.

So one way or another I hope to have a date within the next few weeks. Will post when I do.
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About Me
Location
20.7
BMI
VSG
Surgery
11/17/2009
Surgery Date
Apr 27, 2009
Member Since

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