Arguments to use in insurance appeal

Jan 10, 2011

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

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