The Appeal
Note: I've decided to unlock this, and it's been slightly revised from the first time I posted it.
April 12, 2008
To whom it may concern:
I am writing to appeal your decision to deny authorization for laparoscopic adjustable gastric band surgery, a decision which was made in February 2008. It is acknowledged that weight-loss surgeries are currently excluded under my insurance plan. However, this surgery is medically necessary to treat my case of Obstructive Sleep Apnea (OSA). I implore you to reconsider coverage for the reasons below.
I have been fighting OSA for nearly my entire adult life. Over the last 12 years I’ve endured excessive daytime sleepiness, fallen into deep depression, nearly died one night when I stopped breathing for an extended period of time during sleep, missed countless hours of work, and suffered through relentless side effects. These include depression, memory loss, mental dullness, sleep paralysis, general fatigue, restlessness, dizziness, numbness in my upper body, morning headaches, mood swings, panic attacks and general lack of motivation.
My sleep apnea has been maddeningly resistant to a myriad of treatments. I’ve had 12 overnight sleep studies since 1996. Each time, doctors have prescribed treatment, which I have followed carefully, but in the end have been ineffective. I have undergone four surgeries in attempt to open my airways:
I have family history of stroke. As you know, OSA dramatically increases the chances of having a heart attack or stroke. On several occasions this year, I have felt as if blood was not circulating properly to my head. On one occasion I nearly passed-out. On another occasion, I fell asleep on my keyboard at work. In 2007 I had five episodes of sleep paralysis, during which I was unable to move my body.
In the space of just 6 years I gained 100 pounds. I’ve made repeated attempts to lose weight, including two periods supervised by medical professionals. Each time, I lost some weight, but it rebounded within months, and I gained more.
Over the same period of time I have missed approximately 500 hours of work, and spent approximately $30,000 on various treatments, devices, medications and copays. (Similarly, my medical insurers have already paid-out over $150,000 in sleep apnea-related medical bills for me; a large portion of those were paid by your company.) It’s become agonizingly clear to me that devices, prescriptions and diets are wholly insufficient to treat my severe OSA.
Obstructive Sleep Apnea is defined as five or more episodes of apnea or hypopnea per hour of sleep in individuals who have excessive daytime sleepiness. According to my most recent sleep study a few months ago, I have 120 apnea/hypopnea episodes per hour; quite literally I can’t even sleep for 30 seconds without stopping breathing. (After my last surgery, the doctor insisted I stay in the hospital overnight because my apnea was so bad.) I am over 100 pounds overweight, I have a BMI of 45, and I score 14 on the Epworth Sleepiness Scale, which is considered dangerous. As you can imagine, I’m at extremely high risk for some very big health problems.
As my condition has grown worse, I have had several episodes where I wake-up choking. My significant-other has witnessed events where I stop breathing for long periods of time. When I lay down to go to sleep, I sometimes really do wonder if it will be for the last time.
My doctors have advised me that I should have weight loss surgery, since we’ve exhausted all other possible treatments (other than tracheotomy). These doctors include Dr. xxxxx, MD (my family doctor), Dr. xxxxx, MD (ENT specialist and surgeon), Dr. xxxxx, MD (sleep specialist), Dr. xxxxx, DMD (sleep dentist) and Dr. xxxxx, MD (gastric surgeon), and they consider the surgery medically necessary to treat my condition. Over the long term, weight loss surgery has a significantly higher success rate than eating/exercise regimens alone. By losing the weight, the layers of fat in my throat will shrink, thereby clearing my airways. This is my only hope of escaping the stranglehold that OSA has had on my life.
I fully understand that under my policy, gastric surgeries are normally not covered as treatment... at least, not for morbid obesity. However I would respectfully ask you to please consider it as treatment for severe and otherwise un-treatable Obstructive Sleep Apnea. We’ve exhausted all other options, and I’m barely able to function. Without the surgery, I fear I will be stuck in an endless cycle of failed attempts to lose weight, risking stroke, losing more work, taking endless prescriptions and aimlessly trying variations on treatments that just don’t work for me.
I am certain that by covering the cost of the Lap Band procedure, your company would save a lot more money down the road. If left untreated, my condition may require even more complex and costly treatment in the future.
I have included a few documents with this letter, notably a letter from my first diagnosis in 1996, as well as the current surgery authorization request from Dr. xxxxx. I am happy to furnish any additional documentation that you may require, including medical records, doctor letters, sleep studies, weight histories, receipts, etc. Please let me know if any additional information will be helpful to my request. I can be reached any time at (xxx) xxx-xxxx (cell/home/work).
Thank you for your immediate attention to this matter.
Sincerely,
Michael _____,
Subscriber # __________
A little dramatic? Yes, but it's all true.
My intention here is not to demonize the insurance company. Read more about it here.
April 12, 2008
To whom it may concern:
I am writing to appeal your decision to deny authorization for laparoscopic adjustable gastric band surgery, a decision which was made in February 2008. It is acknowledged that weight-loss surgeries are currently excluded under my insurance plan. However, this surgery is medically necessary to treat my case of Obstructive Sleep Apnea (OSA). I implore you to reconsider coverage for the reasons below.
I have been fighting OSA for nearly my entire adult life. Over the last 12 years I’ve endured excessive daytime sleepiness, fallen into deep depression, nearly died one night when I stopped breathing for an extended period of time during sleep, missed countless hours of work, and suffered through relentless side effects. These include depression, memory loss, mental dullness, sleep paralysis, general fatigue, restlessness, dizziness, numbness in my upper body, morning headaches, mood swings, panic attacks and general lack of motivation.
My sleep apnea has been maddeningly resistant to a myriad of treatments. I’ve had 12 overnight sleep studies since 1996. Each time, doctors have prescribed treatment, which I have followed carefully, but in the end have been ineffective. I have undergone four surgeries in attempt to open my airways:
- Tonsillectomy/Adenoidectomy in 1996
- Uvulapalatopharyngoplasty (UPPP) in 1997
- (Repeat) Adenoidectomy in 2003
- Sinus surgery in 2007 (cauterization of turbinates, removal of scar tissue and clearing of sinuses)
I have family history of stroke. As you know, OSA dramatically increases the chances of having a heart attack or stroke. On several occasions this year, I have felt as if blood was not circulating properly to my head. On one occasion I nearly passed-out. On another occasion, I fell asleep on my keyboard at work. In 2007 I had five episodes of sleep paralysis, during which I was unable to move my body.
In the space of just 6 years I gained 100 pounds. I’ve made repeated attempts to lose weight, including two periods supervised by medical professionals. Each time, I lost some weight, but it rebounded within months, and I gained more.
Over the same period of time I have missed approximately 500 hours of work, and spent approximately $30,000 on various treatments, devices, medications and copays. (Similarly, my medical insurers have already paid-out over $150,000 in sleep apnea-related medical bills for me; a large portion of those were paid by your company.) It’s become agonizingly clear to me that devices, prescriptions and diets are wholly insufficient to treat my severe OSA.
Obstructive Sleep Apnea is defined as five or more episodes of apnea or hypopnea per hour of sleep in individuals who have excessive daytime sleepiness. According to my most recent sleep study a few months ago, I have 120 apnea/hypopnea episodes per hour; quite literally I can’t even sleep for 30 seconds without stopping breathing. (After my last surgery, the doctor insisted I stay in the hospital overnight because my apnea was so bad.) I am over 100 pounds overweight, I have a BMI of 45, and I score 14 on the Epworth Sleepiness Scale, which is considered dangerous. As you can imagine, I’m at extremely high risk for some very big health problems.
As my condition has grown worse, I have had several episodes where I wake-up choking. My significant-other has witnessed events where I stop breathing for long periods of time. When I lay down to go to sleep, I sometimes really do wonder if it will be for the last time.
My doctors have advised me that I should have weight loss surgery, since we’ve exhausted all other possible treatments (other than tracheotomy). These doctors include Dr. xxxxx, MD (my family doctor), Dr. xxxxx, MD (ENT specialist and surgeon), Dr. xxxxx, MD (sleep specialist), Dr. xxxxx, DMD (sleep dentist) and Dr. xxxxx, MD (gastric surgeon), and they consider the surgery medically necessary to treat my condition. Over the long term, weight loss surgery has a significantly higher success rate than eating/exercise regimens alone. By losing the weight, the layers of fat in my throat will shrink, thereby clearing my airways. This is my only hope of escaping the stranglehold that OSA has had on my life.
I fully understand that under my policy, gastric surgeries are normally not covered as treatment... at least, not for morbid obesity. However I would respectfully ask you to please consider it as treatment for severe and otherwise un-treatable Obstructive Sleep Apnea. We’ve exhausted all other options, and I’m barely able to function. Without the surgery, I fear I will be stuck in an endless cycle of failed attempts to lose weight, risking stroke, losing more work, taking endless prescriptions and aimlessly trying variations on treatments that just don’t work for me.
I am certain that by covering the cost of the Lap Band procedure, your company would save a lot more money down the road. If left untreated, my condition may require even more complex and costly treatment in the future.
I have included a few documents with this letter, notably a letter from my first diagnosis in 1996, as well as the current surgery authorization request from Dr. xxxxx. I am happy to furnish any additional documentation that you may require, including medical records, doctor letters, sleep studies, weight histories, receipts, etc. Please let me know if any additional information will be helpful to my request. I can be reached any time at (xxx) xxx-xxxx (cell/home/work).
Thank you for your immediate attention to this matter.
Sincerely,
Michael _____,
Subscriber # __________
A little dramatic? Yes, but it's all true.
My intention here is not to demonize the insurance company. Read more about it here.