More arguments that the VSG is a standard of care

Jan 25, 2011

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.

[1] [2] [3] [4] [5] See [6] Documentation of these consultations appears in Appendix A of this memo. [7] [8] and


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Oct 21, 2010
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