Month Date YearYour Insurance Company’s NamePO BoxCity, State, ZipcodeTelephone #: (xxx) xxx-xxxxFax #: (xxx) xxx-xxxx IN REFERENCE TO: APPEAL OF DENIAL OF SERVICE FORRequest for Pre-approval for Laparoscopic Gastric Bypass(CPT-4 Code = 43846)or open use code________________As Treatment for Morbid Obesity /Clinically Severe Obesity(ICD-9 Code = 278.01)Member: Ms. Your First Name Your Last NameYour Address MEMBER ID #:Note: (Patient meets both Milliman and Robertson and U.S. FederalGuidelines -1. Milliman and Robertson Guidelines for the Gastric Surgery forClinically Severe Obesity 15 CPT-4: 43842, 43846 and2. U.S. Federal Clinical Practice Guidelines for the Treatmentof Obesity 16 set down in National Institutes of Health ConsensusConference. Released June 17, 1998, the Federal guidelines on theobesity were by the National Heart, Lung, and Blood Institute (NHLBI),in cooperation with the National Institute of Diabetes and Digestiveand Kidney Diseases (NIDDK)).Dear Sir or Madam:I am writing to appeal the denial of service request prior approval forlaparoscopic gastric bypass for Ms. Your First Name Your Last Name .Generally denial of service for gastric bypass by insurance companiesare of one of two types claims that gastric bypass is an non-coveredservice (usually through contract exclusion) or a determination of lackof medical necessity. In the following detailed appeal I will providecompelling evidence that in Ms. Your Last Name ’s case neither is a

reasonable or rational justification for the denial of the service forthis patient.First I will deal in detail for the issue of medical necessity. Obesityis probably the most common chronic disease in our country. As much as33% of U.S. the population is over-weight, with the percentage higheramong women and minorities. Obesity has been unequivocally been shownto increase the risk of hypertension, coronary artery disease, non-insulin-dependent diabetes mellitus, gallbladder disease, sleep apnea,gout, and certain types of cancer (e.g., prostate cancer). Althoughobesity is a chronic disease with adverse health consequences, in oursociety it carries such a stigma that many people -- including healthprofessionals -- don't believe that the obese person deserves anysympathy at all, let alone medical treatment for the condition. Obesityis a physical disability that is intensely stigmatized in our society.Studies have shown a striking inverse relationship between obesity andsocioeconomic status, especially among women. Being overweight has aparticularly deleterious effect on socioeconomic attainment. Therelationship between overweight (body-mass index above the 95thpercentile for age and sex -- which in many cases is not even obese)and educational attainment, marital status, household income, and self-esteem in 10,039 randomly selected individuals aged 16 to 24 years ofage. To assess the social consequences of obesity, the investigatorscompared disability from obesity with that associated with other formsof chronic illness.The prevalence of overweight was 3.4% in males and 3.0% in females(5.8% in black females versus 2.5% in non-Hispanic whites). Seven yearslater, the overweight women were less educated (0.3 fewer years ofschool), less likely to be married (10%), had lower household incomes($6,710 less), and had 10% higher rates of household poverty than womenwho had not been overweight, independent of baseline socioeconomicstatus and aptitude test scores. Similar trends were found among themen. It has been said that obesity is due to low socioeconomic status,yet the results of this study indicate that the inverse is also true:low socioeconomic status is caused by obesity.Subjects with chronic health problems who were not obese did not sufferfrom the same low attainments. Obesity is a stigma that results indiscrimination is the explanation for this social disability. It is thepublic nature of obesity that invites discrimination. (Gortmaker SL etal. N Engl J Med. 1993: 329: 1008-1012.) In a recent issue of JAMA,Robert Yaes wrote, "Certainly, at a time when it is fashionable toclaim that alcoholism and drug abuse are illnesses whose treatmentshould be covered by health insurance, it is inconsistent to blame fatpeople for their own condition." Yaes, a physician who is himselfobese, concluded, "In our culture, obesity is perceived as more of acosmetic problem than a medical problem.“ (Yaes RJ. JAMA. 1993; 270:1423.)We hold these truths to be self evident that all are created equal andare deserving of our compassion. This includes obese persons who mightbe regarded as disabled or handicapped. The importance of a person doesnot reside in the functioning of the body or mind or in the person'sability to contribute to society, but rather in his or her intrinsichumanity.

All people, including obese persons, are equitable treatment for theirillness. The role of the physician and the responsibility of theinsurance company are to provide fair and equal appropriate medicalcare to the individuals for whom they are responsible. Our responseshould be characterized by an attitude of compassion, free ofcondescension and marked by action. It is our combined responsibilityto serve our patients with compassion.Poking fun at overweight people is routine for some, and discriminationagainst the overweight is common. In the United States, heavy peoplefrequently are targets of ridicule. "I don't feel there's a reason foranybody to let themselves go that badly," one woman said. Another womansaid it makes her laugh. "Right now, it seems more acceptable to talkabout hatred of weight than any other factor like gender, race,ethnicity, etc.," said Professor Esther Rothblum, a Stanford Universityresearcher. "Some people have said it seems to be our last area whereit's absolutely legitimate to discriminate." It's not easy tochallenge weight discrimination. In Michigan such discrimination isoutlawed. Everywhere else, alleged victims are turning to another tool,the Americans with Disabilities Act, which has been used successfullyto support that obesity is a disability.The Medical Necessity for the Surgical Treatment of Ms. Your Last Name’s Clinically Severe ObesityAs I stated in my original letter Ms. Your Last Name is a 58 year oldWhite Female. Ms. Your Last Name is 5 feet 6 inches tall and weighs310 lbs. This gives her a Body Mass Index (BMI) of 50.The body mass index is calculated by dividing a person's weight inkilograms by their height in meters squared. When a man's BMI is over27.8, or woman's exceeds 27.3, that person is considered obese. Thedegree of obesity associated with a particular BMI ranges from mildobesity at a BMI near 27, moderate obesity at a BMI between 27 - 30,severe obesity at 30 - 35, to very severe obesity for patients with aBMI of 40 or greater 1,2,3. Therefore, Ms. Your Last Name may beclassified as being very severely obese. The major health risks ofobesity increase in a curvilinear relationship, with prevalencesincreasing progressively and disproportionately with increasing weight.Weight increases beginning during adulthood and continuing for manyyears have the greatest adverse affects. The annual number of deaths inAmerica attributable to obesity has been estimated to be 300,000 deathsper year4, 5. With her abnormally high BMI Ms. Your Last Name is atan estimated 204 percent increased risk of death at her present weight.Ms. Your Last Name has tried several diets to lose weight. Theoutcome of these efforts was that Ms. Your Last Name lost some amountof weight but then regained all of the lost weight and more. Thepatient states that she has tried numerous weight loss programsincluding TOPS, Weight Watchers, Nutrisystems, Physician's Weight LossCenters, Metabolic Research Center, Texas Nutrition Center, Weight Lossby Lois, Optifast, Metracal, AYDS, Slim Fast, Herbs, Dexamyl, Fastin,Fen-Phen, Redux, Pondimin, Meridia, many low fat diets, Bible programs,Hypnosis, and every popular diet she has heard about. She states thaton every diet that she has tried, she has lost 5-50 pounds but as soonas she stoppe