More VSG appeal verbiage

Mar 06, 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

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