So I was offically denied by my insurance company BCBSNC Oct. 31. My surgeon's office called me to let me know, they consider it investigational, did I want to schedule a different surgery? Uh no! I will appeal. Didn't surprise me they denied but still disappointed. So I hit the boards on OH seeking appeal advice. Put my research together and wrote a kick ass letter, if I do say so myself. The format of the letter came from vsgfaq.com but then i put my own information and thoughts in. I have the letter and research links at the bottom of this blog.
I was slightly perturbed with the ins. coordinator at my surgeon's office because I had asked her on the phone if Dr. Enochs could write a letter for me to go with my appeal. Her response was no because there is nothing medical to substantiate the sleeve over RNY. I told her that in the consult he recommended the sleeve so couldnt he just say that and give his reasons why it shouldn't be investigational...I will ask was her response. So I wrote a nice email explaining I understand Dr. Enochs can not medically give a reason for the sleeve over RNY, being I am a candidate for all surgeries but could he just document in his professional opinion why the sleeve shouldn't be considered investigational. Her response, no again..nothing medical.blah blah. Grrr! Did I not make my point? Did I not pay you a 400.00 consult fee? Are you not going to make killer money off this surgery? You can't write a 5 minute letter to fight for your patient? Really? If I had money lieing around to pay another consult fee to another surgeon, I would because that ticked me off. She made me feel like I was being pushed toward RNY because it was an easier route for THEM and I should just happily go through the production line. I am sorry, this is my body. THEY don't have to live with the choice I make. I know there are plenty of people that RNY and lapband have worked great for them. I am happy for them but the risks and possible complications are not for me. Don't get me wrong, I think Dr. Enochs is a competent surgeon and I like his bedside manner and feel confident he can perform this surgery but his staff make me feel like I am a burden. I was going to wait and submit my appeal after my Nov 18th appt so I could talk to Dr. Enochs personally and try to get my point across in person since maybe my message was garbled by a 3rd party but decided to go ahead and submit. I feel confident in my letter and research alone at this point. I will cross that bridge if I have to do a 2nd appeal.
They have 30 days to respond to my appeal. We shall see if my letter dazzles them. Hopefully my next post will say Approved!!
Here is the letter:
November 7, 2008
Blue Cross Blue Shield of North Carolina
Member Rights and Appeals Department – Level 1 Appeal
To Whom It May Concern:
I’m hereby requesting a reversal of the initial denial for the bariatric procedure known as the Vertical Sleeve Gastrectomy/Gastric Sleeve (VSG-CPT code 43843) by Blue Cross Blue Shield of NC (BCBSNC). This request is made due to BCBSNC’s assessment that the VSG is experimental/investigational as well as preference of surgery choice VSG being considered investigational is at best, misguided, and at worst, a knowing endangerment of my health that could have risk management consequences if I have to have another procedure and there is an adverse outcome. I agree with the experts and my surgeon; that the Vertical Sleeve Gastrectomy (VSG) or Gastric Sleeve (GS) surgery is the safest and best weight loss route for me. I’m confident that after reviewing the attached documentation the committee will agree and grant approval for the VSG.
My doctors consider weight loss surgery as ‘medically necessary’ and I have met all the requirements to establish medical necessity per BCBSNC medical policy (attachment 1). I am a 36 year super morbidly obese female with mostly obesity related co-morbidities that will improve or go away entirely with WLS. My current weight is 381 lbs with a BMI of 61 and have been 300 plus for more than ten years. My co-morbidities are sleep apnea, GERD, edema onset, hiatal hernia, difficulty breathing, trouble sleeping, joint pain and back pain, I can not walk or stand for more than 10 minutes; the excess weight causes tremendous pressure on my back, legs and joints. This has caused me to not be able to fully function in daily activities, enjoy life or exercise presenting a more sedentary lifestyle just waiting for additional co-morbidities to set in. Not only am I at a health risk for heart disease, diabetes, heart attack, stroke, hypertension because of my weight alone, these co-morbidities are all in my blood line, which puts me at a greater health risk. My father and mother both have type II diabetes. My father also has hypertension, neuropathy, has had heart bypass surgery as well as numerous strokes. I am volume eater, portion control and continuous hunger are my issues which is why I strongly believe VSG is the perfect WLS choice for my life without having to re-route my intestines, subject myself to increased dumping and possible higher risk of complications, malabsortption issues and possible future side effects that many RNY patients have seen that include malnutrition, bowel obstruction, hernia, depression,
gastritis, increased GERD plus many more minor and major complications including death. This was seen in study after study during my research.
Given the VSG’s track record it is the best option when compared to other bariatric choices, such as the Gastric bypass (RNY) or Lapband. The VSG procedure has been used successfully for weight loss since 1976 as demonstrated by medical studies (attachment 2) with out the many side affects or complications associated with the RNY or the LabBand. While any surgery carries risks, and I’m well aware of these, this surgery is not riskier than other procedures; in fact statistics show that it is safer. Documented studies show that it will generate between 60 to 80% of Excess Body Weight Loss (EBWL) in 6 to 12 months, many patients have achieved 90 to 100% EBWL during the same time periods with weight loss of 100lbs. to 200lbs. The complication rate of the RNY is 6.5%, and it’s considered the “Gold Standard”, compared to the complication rate of 1.5% for the VSG in the last 10 years and with similar or better weight loss results. See many examples of attached supporting documentation (attachment 3) that shows VSG is less invasive with the same results as RNY and/or Lapband. I have also read many encouraging stories from real people on Obesityhelp.com VSG forum who are 1-4 years out and have no regrets from having chosen this surgery and have had great success in losing 100-200 lbs as well as many documented stories on other Obesityhelp.com forums of RNY and lap band patients having revisions to VSG and DS (Duodenal Switch) because of complications or lack of weight loss and sometimes weight regain. The DS has been around for many years and is approved by BCBSNC in patients with a BMI>50; the VSG is simply the first portion of this surgery minus the malabsorptive portion of the surgery, which can be completed if necessary but why subject your body to malabsorption issues and further complications if a restrictive procedure will accomplish the same goal. The VSG has been proven to perform well as a stand alone procedure.
After reviewing BCBSNC Medical Policies in regard to Bariatric Surgery I would like to point out two items.
First, “When Surgery for Morbid Obesity is not covered”, (page 6, attachment 1) quote:
2. When the procedure is considered investigational, including but not limited to f. Sleeve gastrectomy, either as the sole procedure or as one step in a staged procedure
How long does a procedure have to be studied before it is no longer considered investigational? The LapBand gained approval for general use in less than 5 years, it is an approved procedure under our plan .There are a number of studies available dating back to 2001 and 2002 that lasted at least 3 years, I have enclosed several (attachment 3) Just these examples alone that I could find show that studies have been performed longer than 3 years for VSG. One study measuring Anemia on patients having this surgery dates back to 1976, only back then the procedure was called Gastric Exclusion (attachment 3).
Second: Surgery types (page 2, attachment 1) quote:
6. Sleeve gastrectomy (no specific CPT code). A "sleeve" gastrectomy is an alternative approach to gastrectomy that can be performed on its own, or in combination with malabsorptive procedures (most commonly biliopancreatic diversion with duodenal switch). In this procedure, the greater curvature of the stomach is resected from the angle of His to the distal antrum, resulting in a stomach remnant shaped like a tube or "sleeve". The pyloric sphincter is preserved, resulting in a more physiologic transit of food from the stomach to the duodenum, and avoiding the "dumping syndrome" (overly rapid transport of food through stomach into intestines) that is seen with distal gastrectomy. This procedure is relatively simple to perform, and can be done by the open or laparoscopic technique. Some surgeons have proposed this as the first in a two-stage procedure for very high-risk patients. Weight loss following sleeve gastrectomy may improve a patient’s overall medical status, and thus reduce the risk of a subsequent more extensive malabsorptive procedure, such as biliopancreatic diversion.
I’m in complete agreement of this statement. BCBSNC’s own medical policy makes positive affirmation of the VSG surgery, which further solidifies my choice in surgery.
I believe that our plan should adapt this surgery as a covered service not only for its many health related advantages but also because it is a cost effective choice compared to ALL other surgeries that are considered “proven”. A vast number of medical experts on the issue of bariatric surgeries are in agreement that the VSG is quickly gaining acceptance when compared to the RNY and will become the surgery of choice for weight loss, Among them Dr John R. Romanelli, MD FACS in his article Laparoscopic Sleeve Gastrectomy: The newest front in the battle against Obesity, published in WLS Lifestyles, fall of 06. His name can be “Googled”. While the Peer Review Committee has not yet considered this surgery for review, it is acclaimed by experts in the bariatric field and my surgeon, as safe, effective, with less complication, side affects and a viable option for weight loss. Additionally other BCBS policies (attachment 4) including Federal BCBS and Carefirst BCBS are adapting the surgery as medically necessary and I have read instances from other Obesityhelp.com forum members where BCBS insurance companies, including Anthem BCBS are overturning their initial denial of the VSG once supporting documentation was received supporting it being non-investigational. I hope BCBSNC follows the example of fellow BCBS policies.
I was pleased and encouraged to find that my health plan covers bariatric surgery and although this procedure is considered investigational by some, there is a body of undisputable evidence showing it to be sound, safe and successful in achieving it’s goal and probably superior to other weight loss surgery options, with many less side affects and complications; but most importantly, the best procedure for my current medical conditions and future wellbeing.
I trust that the attached information will provide additional information that will make possible a reversal of the initial denial. Attached you will find the documents relating to my appeal for consideration of the VSG for medically necessary weight loss surgery as a covered service under the Bariatric Surgery benefits of our health plan. I encourage this committee to please review the documented experts opinion and recommendations on bariatric surgery and approve this procedure.
· BCBSNC Medical Policy
· Seven significant studies and stories supporting and documenting Vertical Sleeve Gastrectomy (including misc. documentation and articles)
· BCBSNC denial letter
· BCBS Carefirst Medical Policy/FEP BCBS Medical Policy
· BCBSNC Appeal Form
Thank you for your expedited consideration in this matter as I await a reversal of the initial denial.
The first is a study that was done from 1976 to 1982 to check on vitamin levels and nutrition of "Gastric Exclusion for treatment of Obesity", I was searching under one of the alternative names for VSG and this one came up. I hope it is correct. I could not tell because it did not mention the VSG or RNY. Thanks Mercy Q
The next one was done between 2/01 and 5/02 with patient's over 50 yrs old. Thanks Mercy Q