Tuesday, December 2, 2008

Shot down again

Well BCBS didn't care for my appeal as I received my 2nd denial letter on Nov. 21st stating that there was not enough evidence to support the sleeve as being non investigational , therefore it is considered non-medically necessary and the denial will be upheld. Uggghhh!!! So what did I do? Went to bed, sulked, ate a whole bunch, then got mad at myself becuase that is why I am fat to begin with. Decided to do nothing for a few days, then I got busy on my 2nd level appeal letter and some more documentation. I planned on mailing it that Wed. before Thanksgiving but I forgot so I mailed it yesterday. It is posted below along with the research links. Keep your fingers crossed!
Speaking of Thanksgiving, it is my favorite time of the year because after spending time with family, my sister in law and I sit up all night going through papers and head out about 3am to go Black Friday shopping. I absolutely love doing this! But this year I was afraid because of the back pain I had been experiencing and I had every reason to be afraid come that morning. My back and feet ached so bad. At one point, I had to go sit in the van, I was so angry at myself and the fat and the Graves Disease for being this way. It was all so clear once again of why I need this surgery.

2nd level appeal letter

To Whom It May Concern:

This letter comes in response to my recent denial dated November 21, 2008 for Weight Loss Surgery (WLS). I am writing this letter to implore that you reverse the decision not to approve Vertical Sleeve Gastrectomy (VSG) surgery on the basis it is considered investigational, therefore not medically necessary. In this letter I will explain why VSG is the best surgery for me and dispute BCBSNC’s assessment that VSG is investigational by asking you to review my Level 1 Appeal packet documentation as well as offering additional facts to dispute this claim. I am confident that you will reverse denial upon reviewing this additional information.

It has been established that WLS is medically necessary per my doctors, surgeon and BCBSNC’s medical policy (Attached in Level 1 Appeal packet) and I am grateful WLS is an option for me. I am even more appreciative of the fact that there is more than one WLS to choose from to accommodate a person’s medical and psychological needs. I have spent years researching different types of WLS; the side effects, lifestyle changes, the risks, the pros and the cons. I have read story after story of Gastric Bypass (RNY) and Lap Band being the perfect surgery for one individual, but not the next. I have read how one person’s body adapts to the changes from RNY or Lap band and the next person is continually sick from throwing up, dehydration, diarrhea, malnutrition, band slippage, band erosion; as well as suffering embarrassing moments in public by an abrupt exit because they ate too fast or ate the wrong food and had to make it to a restroom quick.
This is one of the many reasons I feel VSG is the best option for me and my lifestyle. It is the one WLS available that offers the most normalcy post op. There is no re-routing of my intestines so there is less malnutrition risk and complications; the stomach stays in tact, it remains a fully functioning stomach so there is minimum chance of dumping and complications. If you take a look at the attached surgery comparison chart you will see that VSG is the optimum choice. I do realize it is still a tool and as with all other WLS, I have to do my part in order to succeed. As I stated in my initial appeal letter, I am a morbidly obese female weighing 379 lbs with a BMI of 61 with mostly obese related co-morbidities that will improve or go away completely with weight loss. This surgery will open the door for a new life for me. I will no longer feel like a kid being punished sitting at their bedroom window watching the other kids play outside.

Partial Gastrectomies have been done on patients suffering from stomach cancer and peptic ulcers for well over 100 years so we know a patient can live successfully with part of the stomach removed. The first gastrectomy was performed by Theodor Billroth in 1881 on a patient with antral carcinoma. The procedure itself has been of course modified and improved over the years just as the original Vertical Gastroplasty of the 1970’s and 1980’s has made the pathway for the significantly improved Vertical Sleeve Gastrectomy. VSG was first performed in 1993 by Dr. Jamieson in England and has since been refined and improved into the VSG we know today by Dr. Gagner in 2001. The VSG has been performed for 15 years and as we know it today for the last 7 years. This is a far cry from an investigational surgery. The results from the studies submitted in my initial appeal packet speak for themselves as well as the people I correspond with on a daily basis on Obesityhelp.com forum (
http://www.obesityhelp.com/forums/vsg/ ) that are real life examples of the success of the VSG with weight loss in excess of 100 lbs with no major complications post op. Laparoscopic Associates of San Francisco has a two year study that can be viewed at www.facs.org/education/gs2004/gs33lee.pdf as a slideshow. I am confident the information provided is significant enough to disprove VSG as an investigational surgery. More insurance companies including BCBS Carefirst and Federal BCBS are adapting VSG in with their policies; this is further clarification this surgery is no longer considered investigational.

Please take a closer look at my initial Appeal Packet as well as the additional documentation attached. I am excited to begin a new life with the surgery that will most benefit me. I look forward to hearing from you soon with good news of a reversal of the initial denial. Thank you for your time.


Research links: