Friday, August 1, 2014

My Personal Appeal to BCBS

For my 300th post today, I want to share with you all my appeal to my insurance company, which I will be sending to them today:



To whom it may concern:

Please accept this letter as supporting evidence for an appeal to BCBSNC’s decision to deny coverage for revision of bariatric surgery from my current Lap Band to roux en Y Gastric Bypass.  It is my understanding, based on your letter of denial dated 02June2014 (initial submission) and again 22July2014 (peer-to-peer review between Dr. Jin Yoo and Dr. Lawrence Woo), that this procedure has been denied because “there is no perioperative or late complication of previous bariatric surgery per coverage policy AND there is insufficient serial records that there has been post-operative compliance with diet after the previous bariatric procedure, 9/17/12”. 

In summary, I refute that there has been no perioperative or late complication of previous bariatric surgery, as I have been diagnosed and received treatment for GERD only post-lap band placement.  Other post-operative complications include polyphagia, dysphagia, excessive aggressive lap band adjustments, and failure to reach a healthy weight through no fault of my own.  I also refute that there are insufficient serial records to demonstrate post-operative compliance.  I have submitted 30+ records of adjustment/clinic visits.  However, despite this, my weight loss alone of over 100 pounds should demonstrate irrefutable proof of compliance.  The rest of this letter will serve to explain the medical necessity for revision surgery and disprove the reason for denial from BCBSNC.

As you know, my Lap Band procedure was performed on 17September2012.  My highest documented weight in the months leading to surgery was 344.4 lbs., and my weight on the day of surgery was 327 lbs.  In the months following surgery, I followed my post-op liquid diet fastidiously, transitioned to soft foods, kept my diet between 1000-1200 calories and protein between 60-100g by tracking my food intake on the myfitnesspal phone app and slowly began exercising.  Over the first 18 months, my lowest weight was 238 lbs.  The first months were not easy but the tool was perfect initially.  The Lap Band helped me control my hunger and as I lost weight, it became easier to exercise.  I did not realize how uncomfortable I had become in my body until I began to feel better.

Around March 2013, I began to have problems with my band.  One day it would feel like I could eat as if I didn’t have surgery and then the next day I would experience severe dysphagia causing me to get sick just from drinking water.  There were certain triggers that I knew would cause the dysphagia and make the band feel tight, for example: allergies, stress, and menstruation.  Other times the sources of the tightness and dysphagia were unexplainable.  This complication lead to frequent visits to the have my band filled and unfilled.  In addition to clinic visits for unfills, I went to the Emergency Room at Durham Regional Hospital in April 2013 for an unfill of my band due to dysphagia.  I was unable to swallow my own saliva by the time I arrived at the ER that day.

The discomfort from my band began to get worse when I started experiencing reflux.  I did not have issues with acid reflux prior to surgery, but I began to realize the reflux could be the reason for my band feeling ‘tighter’, or for food/water coming back up after eating or drinking.  I have been taking Nexium OTC to help control the discomfort but it is not always successful and I still find myself coping with the discomfort frequently.  On 03July2013, I woke up unable to drink water in the morning.  I thought this feeling would pass; it is often difficult for me to drink anything in the morning without vomiting since having my Lap Band placed, so this has become a new normal for me.  Later in the day I could not eat, drink a protein shake, or even keep water down without it coming back up within a few seconds of swallowing.  This continued until 08July2014 when I went to Dr. Yoo’s office to have a complete unfill of my Lap Band.  I was so relieved after having the band loosened to be able to drink water again and eat, however the problems didn’t end as I was admitted to Duke Regional Hospital on 13July2014 for pain in my chest which was diagnosed as GERD.  It was the most painful experience to date dealing with my band.

In addition to the physical pain associated with the band, I have experienced excessive hunger.  I was first put on Phentermine to help the hunger, but this is not a long-term solution due to health risks associated with Phentermine.  I began to have more aggressive fills, which somewhat helped the hunger, but irritated the reflux.  It seemed to be the only way to control the hunger and continue losing weight or even maintain my weight loss, so I thought I would cope with the reflux.  However, the reflux has become intolerable over the last few months.  Due to the pain and dysphagia, I have gotten fewer Lap Band adjustments (once every 4 weeks, which is normal for the average patient but not enough to control my polyphagia) and my weight has drastically increased.  This morning I weighed 260.2—a 22 pound increase from April 2014 when the reflux began to get worse and I began seeking fewer adjustments to help control the reflux problems.

It is incredibly frustrating that after being such a compliant patient with food, working out diligently, joining a running group and running three 5k races, joining two gyms (Burn Bootcamp in Durham, NC and East Coast Boxing in Cary, NC) that I am still struggling with my weight and pain associated with this band.  I have worked incredibly hard over the last 22 months, and the idea of gaining the weight back that I have lost causes me more emotional turmoil than someone who has never been morbidly obese can possibly understand.  I lose sleep over it.  I go to therapy to talk about how to deal with it and the depression, anxiety, and anger that accompany struggling with this experience.

I have a lengthy family history of obesity and diseases associated with obesity.  My paternal grandmother was so obese that her weight prevented her from walking.   I am terrified of meeting the same fate.  With a family history of obesity, I know the future health complications that I face if I don’t get my weight within a healthy range.  For example, all four of my grandparents and my mother suffer (or suffered prior to death) from diabetes.  My paternal grandmother lost a kidney due to complications of diabetes.  I have a family history of heart disease, hypertension, and sleep apnea.  I am trying so hard to get this under control while I am young, before I have a chance for these obesity related diseases to develop.  That’s why I had the initial Lap Band surgery, and I am not ready to give up on myself or on my health! 

At this point, I strongly believe that surgery to remove the band is unavoidable to cure my current complications--reflux and dysphagia, and I do not want to lose the progress I’ve gained by completely losing any form of a Weight Loss Surgery tool.  The desire to achieve a healthy weight is why I have requested revision to RNY gastric bypass in addition to the fact that gastric bypass is the best surgery option to help my acid reflux.  At 260 lbs., I am not close to a weight that any doctor would consider healthy for a 26 year old 5’8” female.  I know I am at risk of developing the prior mentioned complications due to my current weight, much less if I gain any due to these continued issues with my Lap Band.

I want to continue working hard to get to where I want my health to be.  I just feel that I shouldn’t have to either suffer with polyphagia, dysphagia or acid reflux in order to get there.   Even when I do not have my band tight, the reflux comes and goes.  The episode of reflux that sent me to the ER on 13July2014 was during a period that my band was completely unfilled.  So then, if I chose to keep my band tight because it appears I will have some form of reflux anyway, I require adjustments every two weeks.  That is a lot of time away from work and money to receive an adjustment bimonthly.  It is also a lot of exposure to radiation to receive an adjustment under fluoroscopy every two weeks, but since my aggressive fills require greater amounts of saline than a typical Lap Band patient, it would not be safe to do them without the fluoroscopy component.  The average Lap Band patient receives around 0.5 CC at an adjustment every 4-6 weeks, while I’ve continually needed anywhere between 1.0-2.0 CC saline at each adjustment every 2 weeks.  If we did the adjustment without the fluoroscopy machine and I received the usual 0.5 CC adjustment, it wouldn’t be nearly enough to help the polyphagia, and if Dr. Yoo were to give me 1.0-2.0 CC of saline without checking the adjustment under fluoroscopy, the chances of ending up with an overly tight band in the emergency room is much higher.  The only solution for my aggressive adjustments is for them to be performed bimonthly with the use of the fluoroscopy machine to ensure my band is tight enough to treat my polyphagia but not too tight. I often fear how that is affecting my reproductive organs and my future ability to have children at only 26 years old by continually exposing my body to radiation every other week under the fluoroscopy machine.

I have done everything Dr. Yoo has asked me to do to be a successful patient.  I’ve counted calories.  I’ve exercised on top of more exercise.  I’ve come in for my adjustment appointments at a rate that is TWICE the normal Lap Band patient.  It baffles me that BCBS can make the assertion that “there is insufficient serial records that there has been post-operative compliance with diet after the previous bariatric procedure”.  I would truly like to know how an individual loses 100+ pounds without compliance or how 30+ follow-up appointments in 22 months fails to provide sufficient serial records.  If this is NOT compliance, how then does BCBS define compliance?  I have a copy of the current Coverage for Bariatric Surgery policy, and nowhere does the policy define what compliance is or is not.  In addition to my records of follow-up visits and Lap Band adjustments, a letter was included from a nutritionist, Ellen Michal, stating that she had no nutritional concerns for me and Dr. Yoo vouched for my compliance in the peer-to-peer review.  I feel that BCBS is just looking for a reason to deny my case, and cannot find a valid reason, as ‘insufficient serial records that there has been post-operative compliance’ is certainly not legitimate.

When I changed jobs in March, I looked at my benefits information and realized pretty quickly that the insurance offered through my new company would not fulfill my needs as a bariatric surgery patient.  It was not a hard decision at the time to choose BCBS as my insurance provider, because BCBS was the company that made my initial weight loss surgery possible.  I even read through the benefits for bariatric coverage and came to the conclusion that BCBS would be the best option for me to correct the issues I have struggled with while having my Lap Band.  I had confidence that my health and wellbeing as a patient would be taken best care of with your company, but I am beginning to wonder if I was wrong.  I did not have a problem paying $332 per month for health insurance through BlueCross BlueShield, as opposed to the $42 per month for the insurance offered by my work, when I thought it was in the best interest of my health.  However, I no longer believe BCBSNC is putting what is in my best interest first. 

I have been obese my whole life, so perhaps I should be accustomed to being bullied about my weight.  But, the fact is that I am not used to it in a professional setting.  It is true that fat shaming is one of the last socially acceptable forms of discrimination, but it’s something that after losing over 100 pounds I am faced with much less frequently.  After receiving a denial for revision from Lap Band surgery to RNY gastric bypass, and then a denial from Dr. Yoo’s peer-to-peer review with Dr. Lawrence Wu with no credible explanation for the denial, it occurred to me that BlueCross BlueShield is practicing this form of bullying because the reason for alleges that I have been non-compliant, therefore the issues I am experiencing are through my own fault.  When I am told no, and the blame is placed on me, BCBSNC expects me to give up like I would’ve in middle school when I was picked on for being fat.  Two years ago at 344.4 lbs. and with a lot less self-confidence, I might have given up more easily, but today I realize my health and quality of life is worth fighting for.

Please take the appropriate action and reverse this decision in the best interest of my health in order to treat my GERD, polyphagia, and prevent future obesity related health complications. While I’ve been compliant and successful at losing 100+ lbs., I am still obese and I fear the repercussions of my obesity in combination with my poor family history.  I strongly feel that roux en Y is my only option to treat these medical problems.  This IS a medical necessity as I am having postoperative complications due to my Lap Band and am still obese.  If revised to RNY Gastric Bypass I will continue to be the hard working, very compliant patient that I have been since my initial weight loss surgery.  Please make my health a priority to your company.

Kind regards,

 

 

4 comments:

  1. BOOM! ROASTED. If that doesn't do it, I don't know what will.

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  2. good letter! wishing you well.

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  3. Hi Hollee - I am a patient of Dr. Yoo's as well. I am trying to get a revision from lap band to RNY. They are supposed to submit to BCBSNC later this week. Did the Peer to Peer review not work? I can't believe BC is being this difficult. I will be devastated if I get denied.

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    1. Dr. Yoo's peer to peer was denied 16 short hours later. I can't believe them either. Fingers crossed that this appeal does the trick. Prepare yourself mentally for a denial and the necessity to appeal, if you get approved you will be thrilled and if you get denied it will not be quite so devastating. I wish you luck!

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