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I finally got to a normal BMI (25).  This has been a great journey, and I'm still hoping to lose a few pounds to put me safely in normal territory.  Thanks to everyone who supported me!

I just learned that BCBS will cover my procedure.  In addition to submitting the appeal to OPM (which I still haven't heard back from), I had my doc re-submit to insurance directly with my new apnea finding.  After a few weeks, they approved the surgery.  Whew!  VSG date:  June 6, 2011.

The benefit plan language on bariatric surgery (2010 brochure, page 54) says that it covers surgical procedures:

 

“ordered and billed by a physician, such as…Gastric restrictive procedures…to treat morbid obesity—a condition in which an individual has a Body Mass Index (BMI) of 40 or more, or an individual with a BMI of 35 or more with co-morbidities who has failed conservative treatment.” 

 

My application for prior approval clearly meets these guidelines:

·        The SG a gastric restrictive procedure.

·     It has been ordered by my physician. 

·     I have a BMI of 35 with co-morbidities.

·     Conservative treatment has failed.

 

So as I understand it, the issue at hand is whether the SG procedure is consistent with the standard of care in the U.S. for weight loss surgery (WLS) candidates with BMI < 50.  I’ll confine the facts that I provide to that issue.  If there are other reasons BCBS FEP is denying coverage of the procedure that are not expressed in the Adverse Decision letter, I simply ask for another opportunity to appeal those other grounds in another submission.

 

This appeal provides facts that support the conclusion that the SG is appropriate for me and consistent with the standard of care.   The appeal reviews relevant statements and research by leading medical authorities, assesses my doctor’s expertise to determine the standard of care, and documents precedents for BCBS FEP approving SG in WLS candidates with a BMI under 50.

 

 

1.     The Sleeve Gastrectomy:  Background [1]

 

The SG is a bariatric surgical procedure that offers an excellent alternative to both gastric bypass and adjustable gastric banding. It is not yet as common as Roux-en-Y gastric bypass (RnY) and gastric banding, but it is quickly gaining expert proponents and enthusiastic recipients.  It was originally developed as a first stage in a two-stage approach for the highest-risk patients, but it is now widely recognized as a safe and effective stand alone treatment for morbid obesity.

 

Perhaps the biggest advantage of the SG lies in the fact that it does not involve any bypass of the intestinal tract so that patients do not experience the complications of intestinal bypass including intestinal obstruction, osteoporosis, anemia, vitamin deficiency and protein deficiency.

The long-standing 'duodenal switch' procedure is in fact an SG to which a duodenal switch (intestinal bypass) is added.  The SG is becoming the preferred choice for many patients seeking surgical weight loss for many reasons:

·        The surgery removes the portion of the stomach that produces the hormone that stimulates hunger (ghrelin).

·        The stomach is reduced in volume but tends to function normally.

·        The pyloric valve is kept intact which means food enters the stomach in a normal, regulated way, and risks of “dumping syndrome” are virtually eliminated

·        The SG minimizes the chance of an ulcer so anti-inflammatory drugs such as aspirin, Motrin, ibuprofen, and naproxen sodium pose no special risks.

·        Patients can take other oral medications normally without concern about how they are absorbed.

·        The SG involves no intestinal bypass and therefore poses little chance of nutritional deficiencies.

·        Most patients with BMI between 30 and 50kg/M2 achieve their goal weights within 9 to 12 months after surgery.

·        The SG is a safer alternative for high body weight (>400 pound) or medically high-risk patients.

·        It can be done laparoscopically in virtually all patients.

·        The SG is one of the safest bariatric procedures.   

·         Other than titanium staples, no foreign objects would remain like with gastric banding.

·         The SG involves no rerouting of the intestines.

 

 

2.     NIH Guidelines endorse SG for patients with BMI of < 50

 

National Institutes of Health

 

NIH standards for WLS appear in its Guidelines document[2]: 

 

“Weight loss surgery is an option for carefully selected patients with clinically severe obesity (BMI ≥ 40 or  ≥ 35 with comorbid conditions) when less invasive methods of weight loss have failed and the patient is at high risk for obesity-associated morbidity or mortality.”

 

The 1991 guidelines do not mention the SG, but more recent NIH statements do.  According to the National Institutes of Health’s Medline Plus[3] (emphasis added):

 

“If you're very overweight and can't lose pounds with a healthy diet and exercise, surgery might be an option for you. The surgery is usually for men who are at least 100 pounds overweight and women who are at least 80 pounds overweight.  If you are somewhat less overweight, surgery still might be an option if you also have diabetes, heart disease or sleep apnea.”

According to my doctor I should weigh 140 pounds, which makes me 86 pounds overweight.  (This excess weight is equivalent to a person of healthy weight carrying around 10 ½ gallons of water, so you can understand my profound motivation to pursue WLS.) 

 

Regarding the SG in particular, the NIH writes (emphasis added):[4]

“Weight-loss surgery may be an option if you are very obese and have not been able to lose weight through diet and exercise.

 

Vertical sleeve gastrectomy is not a "quick fix" for obesity…This procedure may be recommended for you if you have:

 

·             A body mass index (BMI) of 40 or more. Someone with a BMI of 40 or more is at least 100 pounds over their recommended weight. A normal BMI is between 18.5 and 25.

 

·             A BMI of 35 or more and a serious medical condition that might improve with weight loss. Some of these conditions are sleep apnea, type 2 diabetes, and heart disease.

 

Vertical sleeve gastrectomy has most often been done on patients who are too heavy to safely have other types of weight-loss surgery. A second weight-loss surgery may be needed eventually for some patients.”

 

Conclusion:  The NIH clearly endorses SG for WLS candidates with BMI’s under 50.  Although the NIH notes the more common historical use of SG for high-BMI patients, it does not suggest limiting the SG to only such patients. 

Second International Consensus Summit for Sleeve Gastrectomy, March 19–21, 2009[5]

 

Published online 15 June 2009.

Indications for SG have been increasing, according to this consensus document.  Surgeons who perform bariatric surgeries met at Second International Consensus Summit for SG (ICSSG) to evaluate techniques and results.

Attendees filled out a questionnaire at the meeting, held March 19–22, 2009, in Miami Beach.  Findings are based on 106 questionnaires representing a total of 14,776 SGs.  In 86.3% of procedures, SG was intended as the sole operation.  Mean ± SD percent excess weight loss was as follows: 1 year, 60.7 ± 15.6; 2 years, 64.7 ± 12.9; 3 years, 61.7 ± 11.4; 4 years 64.6 ± 10.5; >4 years, 48.5 ± 8.7.

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%.

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[1] This section is adapted from the websites of leading bariatric surgeons, such as http://www.lapsf.com/vertical-gastrectomy-weight-loss-surgery.php.

[2] See http://www.nhlbi.nih.gov/guidelines/obesity/ob_exsum.pdf

[3] See http://www.nlm.nih.gov/medlineplus/weightlosssurgery.html .

[4] See http://www.nlm.nih.gov/medlineplus/ency/article/007435.htm

[5] http://www.ncbi.nlm.nih.gov/pubmed/19632647

In a letter dated October 14, 2010, Blue Cross BlueShield Federal Employee Program (BCBS FEP) denied prior approval for a Sleeve Gastrectomy (SG) for me as a standalone procedure for the treatment of morbid obesity.    The reason the letter gives for denial was:    “According to the 2010 BlueCross Blue Shield Service Benefit Plan, page 126, medical necessity is determined based on whether a service is consistent with the standards of medical practice in the United States. The clinical information received indicates the member weighs 226 pounds with a body mass index (BMI) of 35.7 and with comorbid diagnosis of gastroesophageal reflex [sic] disease, and asthma. After medical director review of the clinical documentation and the current literature, it has been determined that the request for sleeve gastrectomy is not a standard of care, as it is usually reserved for the extremely obese patients with a BMI exceeding 50. Therefore, the Plan cannot accept the financial responsibility for the requested service.”    PART ONE: CONCLUSIVE EVIDENCE THE SG IS A STANDARD OF CARE AND IS NOT USUALLY RESERVED FOR THE EXTREMELY OBSESE   As I stated in my original appeal, my understanding is that the issue at hand is whether the SG procedure in particular is consistent with a standard of care in the U.S. for me, a weight loss surgery (WLS) candidate with a BMI less than 50, not whether I am in fact an appropriate candidate for weight loss surgery.   In my appeal, which you received last year, I provided extensive clinical evidence supporting the safety and efficacy of the SG, along with information about why it is the only appropriate WLS procedure for me. I also provided evidence that other local plan administrators for BCBS FEP cover the SG for patients with a BMI under 50. Since providing that information I have communicated with literally dozens of people covered by BCBS FEP that have gotten the SG covered, and in each case their starting BMIs were under 50. There is no rational basis for Carefirst BCBS FEP’s claim that the SG is not a standard of care for me when BCBS FEP has already determined that it is for others just like me.    Since preparing my original appeal, I have found other extensive and conclusive evidence that the SG is indeed a standard of care in the US for WLS candidates other than the extremely obese. I present this below.   Under the logic that a standard of care is defined by the care provided by the very best doctors and facilities in the US, I have reviewed the policies of bariatric programs at the top hospitals across the country, with special attention to Blue Distinction Centers for Bariatric Surgery and American Society for Metabolic and Bariatric Surgery (ASMBS) Bariatric Surgery Centers of Excellence. I found that physicians at most of top programs perform SG’s and do NOT reserve them for extremely obese patients.    To illustrate, here are excerpts from the websites of just a few of the many top institutions that do NOT reserve the SG for extremely obese patients. Johns Hopkins Center for Bariatric Surgeryin Baltimore says about the SG (emphasis added):[1]   “The sleeve gastrectomy may be an alternative for those who do not want an adjustable band or have less weight to lose and do not want the malabsorption component of a gastric bypass or duodenal switch.”   Johns Hopkins physicians clearly endorse the SG as an option for patients with a BMI under 50. Carefirst BCBS FEP cannot reasonably claim to have superior understanding of the clinical literature than the world-class experts at Johns Hopkins. The list goes on…   Another leading program, Duke University’s Duke Center for Metabolic and Weight Loss Surgery writes: (emphasis added):[2]   “[The SG] is currently indicated as an alternative to gastric banding for low weight individuals and as a safe option for higher weight individuals. It is occasionally considered a first step in a two-step surgical procedure for high-risk patients.   Massachusetts General Hospital, a teaching hospital of Harvard University in Boston, calls the SG[3]:   “An alternative to gastric banding, this cutting-edge procedure involves removal of three quarters of the stomach.”     And Stanford University’s Bariatric & Metabolic Interdisciplinary Clinic highlights the advantages of the SG without qualification of BMI category (emphasis added)[4]:   “The newest weight loss procedure Stanford is performing is the laparoscopic sleeve gastrectomy. This procedure was first described as the first step of a more complicated procedure, the duodenal switch. Initial weight loss from the sleeve gastrectomy alone was found to be very good (50-60% excess weight loss) at one year without the need for further intervention.   The sleeve gastrectomy provides some advantages, namely no anastomoses (connections between the bowel), no adjustments as needed with the Lap Band, and it’s possible to convert it later to the either the gastric bypass or Lap Band if needed.   The sleeve gastrectomy appears to be a viable option in addition to the Lap Band or gastric bypass for surgical weight loss.”   These statements illustrate the clear position of leading bariatric surgery programs that the SG is a medically appropriate option for patients who might otherwise choose the Lap Band, including patients with a BMI under 50.    To confirm these findings, I directly contacted the bariatric surgery programs at the top three hospitals in the United States as ranked by US News and World Report.[5] The hospitals are Johns Hopkins (Baltimore, MD), the Mayo Clinic (Rochester, MN), and Massachusetts General Hospital (Boston, MA).   Indeed, physicians in all three of these top programs regularly offer the sleeve gastrectomy to WLS candidates with a BMI under 50. Contrary to the claim by BCBS FEP in the Adverse Decision, these top physicians and hospitals do NOT usually reserve the sleeve for “extremely obese patients with a BMI exceeding 50.”    I’m told by staff at the Mayo Clinic that the main reason they tend to do fewer sleeves relative to other procedures on lighter patients is because insurance doesn’t cover it as often, not because it’s not an appropriate standard of care.[6] BCBS cannot reasonably argue that medical necessity is governed by patterns of practice that derive from a lack of insurance coverage. Rather, medical necessity and a standard of care are defined by the care offered by leading physicians and hospitals based on their clinical expertise and scientific judgment, independent of patients’ insurance status.   Importantly, all of the facilities I’ve mentioned here (Mass General, Johns Hopkins, Duke, Stanford, and the Mayo Clinic) are Blue Cross Blue Shield Blue Distinction Centers for Bariatric Surgery,[7] and all of them regularly offer the SG for patients with a BMI under 50. Carefirst BCBS FEP cannot reasonably argue that all of these world-class bariatric surgery programs contravene a standard of care.   According to Allan Korn, MD, Blue Cross and Blue Shield Association’s chief medical officer, “Blue Distinction puts a high value on research and evidence-based health and medical information. Blue Distinction Centers show our commitment to working with doctors and hospitals in communities across the country to identify leading institutions that meet clinically validated quality standards and deliver better overall outcomes in patient care.”[8]If BCBS endorses these facilities and believes they “meet clinically validated quality standards and deliver better overall outcomes in patient care,” then BCBS should recognize that the care they provide constitutes a standard of care.     In conclusion, I have provided conclusive evidence that the sleeve gastrectomy is a standard of care not usually reserved by physicians for the extremely obese. I have shown that for patients in my BMI category, the SG is fully consistent with the care of top hospitals and providers in the United States and that the SG is consistent with the care of providers BCBS itself has endorsed. The only reasonable conclusion from this evidence is that BCBS must reverse its Adverse Decision.

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[1]http://www.hopkinsbayview.org/bariatrics/surgery/options.html#sleevegastrectomy. [2]http://www.dukehealth.org/services/weight_loss_surgery/treatments/sleeve_gastrectomy. [3]http://www.massgeneral.org/generalsurgery/services/treatmentprograms.aspx?id=1522. [4]http://stanfordhospital.org/clinicsmedServices/COE/surgicalServices/generalSurgery/bariatricsurgery/treatment/gastrectomy.html. [5] See http://health.usnews.com/health-news/best-hospitals/articles/2010/07/14/best-hospitals-2010-11-the-honor-roll.html. [6] Documentation of these consultations appears in Appendix A of this memo. [7]http://www.bcbs.com/innovations/bluedistinction/blue-distinction-bariatric/bluedistinctionbariatric.pdf. [8]http://bariatrics.valleyhealthlink.com/About-Us/News.aspx?NewsID=2 and http://www.hallmarkhealth.org/lawrence-memorial-hospital-designated-as-a-blue-distinction-center-for-bariatric-surgery.html.

Hi All,
My insurance company denied covering the sleeve gastrectomy (SG) because they said it isn't a standard of care because it's usually reserved for the "extremely obese with a BMI exceeding 50."  I'm still waiting on the results of my appeal, but thought I'd share some of the material I put in it. 

1.     NIH Guidelines endorse SG for patients with BMI of < 50   National Institutes of Health   NIH standards for WLS appear in its Guidelines document[1]:    “Weight loss surgery is an option for carefully selected patients with clinically severe obesity (BMI ≥ 40 or  ≥ 35 with comorbid conditions) when less invasive methods of weight loss have failed and the patient is at high risk for obesity-associated morbidity or mortality.”   The 1991 guidelines do not mention the SG, but more recent NIH statements do. According to the National Institutes of Health’s Medline Plus[2] (emphasis added):   “If you're very overweight and can't lose pounds with a healthy diet and exercise, surgery might be an option for you. The surgery is usually for men who are at least 100 pounds overweight and women who are at least 80 pounds overweight.  If you are somewhat less overweight, surgery still might be an option if you also have diabetes, heart disease or sleep apnea.” According to my doctor I should weigh 140 pounds, which makes me 86 pounds overweight. (This excess weight is equivalent to a person of healthy weight carrying around 10 ½ gallons of water, so you can understand my profound motivation to pursue WLS.)    Regarding the SG in particular, the NIH writes (emphasis added):[3] “Weight-loss surgery may be an option if you are very obese and have not been able to lose weight through diet and exercise.   Vertical sleeve gastrectomy is not a "quick fix" for obesity…This procedure may be recommended for you if you have:   ·             A body mass index (BMI) of 40 or more. Someone with a BMI of 40 or more is at least 100 pounds over their recommended weight. A normal BMI is between 18.5 and 25.   ·             A BMI of 35 or more and a serious medical condition that might improve with weight loss. Some of these conditions are sleep apnea, type 2 diabetes, and heart disease.   Vertical sleeve gastrectomy has most often been done on patients who are too heavy to safely have other types of weight-loss surgery. A second weight-loss surgery may be needed eventually for some patients.”   Conclusion: The NIH clearly endorses SG for WLS candidates with BMI’s under 50. Although the NIH notes the more common historical use of SG for high-BMI patients, it does not suggest limiting the SG to only such patients.  Second International Consensus Summit for Sleeve Gastrectomy, March 19–21, 2009[4] Published online 15 June 2009. Indications for SG have been increasing, according to this consensus document.  Surgeons who perform bariatric surgeries met at Second International Consensus Summit for SG (ICSSG) to evaluate techniques and results. Attendees filled out a questionnaire at the meeting, held March 19–22, 2009, in Miami Beach. Findings are based on 106 questionnaires representing a total of 14,776 SGs.  In 86.3% of procedures, SG was intended as the sole operation.  Mean ± SD percent excess weight loss was as follows: 1 year, 60.7 ± 15.6; 2 years, 64.7 ± 12.9; 3 years, 61.7 ± 11.4; 4 years 64.6 ± 10.5; >4 years, 48.5 ± 8.7. 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%.

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[1] See http://www.nhlbi.nih.gov/guidelines/obesity/ob_exsum.pdf [2] See http://www.nlm.nih.gov/medlineplus/weightlosssurgery.html . [3] See http://www.nlm.nih.gov/medlineplus/ency/article/007435.htm [4]http://www.ncbi.nlm.nih.gov/pubmed/19632647