Final Letter - Why revision doesn't require a high BMI

Well it's been over a year and I'm in the final few days of my appeal. It's gone all the way to the Federal Office of Personnel Management in D.C. The basic issue is that even though they already agreed that my lap band failed, enough that they paid to remove it, they want me to get my BMI back up to 40 before they do. Crazy huh? But over the weekend I found policy statements for revision from Regence, Medicare and the ASMBS. I put it all in a letter and sent it off for a "hail Mary" pass at getting them to change their minds.

In case it's useful for anyone, here's the letter...

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In October 2009, I submitted an appeal to the OPM regarding a disputed claim for bariatric surgery revision. As the OPM’s review of my appeal comes to a close, I wanted to take a minute and reiterate the details of my case and why I believe that the revision is medically necessary under the guidelines of Regence’s bariatric revision policy. Your review and immediate consideration of this letter is much appreciated. Given that I’ve waited 7 months for an appeals process that should have been completed within 60 days (as per OPM policy), I believe my request for expediency is fair.

In 2006 I was approved for weight loss surgery and underwent a procedure to insert an adjustable gastric band. The procedure was very successful. The band, along with my compliance to the recommended diet and exercise guidelines, helped me to lose nearly 90% of my excess weight. I far exceeded the 65% excess weight loss average for this type of surgery. It was wonderful experience and it changed my life.

Unfortunately, in late 2008 I suffered a complication and the lap band failed. A band slip with pouch dilation, also referred to as stomach prolapse, was confirmed through endoscopy. A secondary failure, a leak in the band tubing that prevented adjustment and appropriate gastric restriction, was found later. Through no fault of my own, the device I relied on to treat my morbid obesity was no longer functional.

Both my primary care physician and bariatric surgeon advised against replacement of the lap band due to risk of future failure and long-term stomach damage. I was advised to pursue a vertical sleeve gastrectomy which was to be performed as part of the overall revision procedure that included removal of the gastric band. My revision request was partially approved by Regence and the lap band was removed in October of 2009.

At the time of the lap band failure I was within 10 pounds of my goal weight. Now, 13 months after the initial pre-certification request and 7 months after removal of the band, I am only 16 pounds under a BMI of 40. Although my initial surgery was approved with a BMI of 35 and co-morbidities, I’ve been advised that I’ll need to gain weight until I reach a BMI of 40 to be approved for the revision. If I do, I will actually weigh more than I did prior to the initial lap band surgery.

In 2008 the American Society for Metabolic & Bariatric Surgery presented medical guidelines for bariatric surgery. Recommendation R163 specifically recommends revision of a bariatric surgical procedure if there were medical complications resulting from the initial surgical procedure. Insurance companies appear to have considered this recommendation when developing their own medical policies for bariatric revision.

Regence’s medical policy for bariatric surgery includes this reference to revision:
“Reoperation to address complications of a bariatric procedure may be considered medically necessary. These include, but are not limited to, staple-line failure, obstruction, stricture, non-absorption resulting in hypoglycemia or malnutrition, weight loss of 20% or more below ideal body weight, band erosion, band migration.”

Nowhere in Regence’s bariatric policy is weight or BMI even suggested as a possible prerequisite to revision surgery.

Most insurance companies appear to have policies that support this basic bariatric revision guideline: if the primary bariatric procedure fails, revision surgery is deemed medically necessary without re-introduction of the same weight and diet requirements of the initial procedure. Even Medicare, whose policies often set the standard for coverage, clearly states the following:

“Previous gastric restrictive procedures that have failed for anatomic or technical reasons (e.g., obstruction, staple dehiscence, etc.) are determined to be medically appropriate for revision without consideration of the initial preoperative criteria.”
(See additional policy examples at the end of this letter.)

In my research, I reviewed the stories of dozens of revision patients (many covered by Federal BCBS). I couldn’t find a single patient who was required to regain their weight as a prerequisite for revision. I couldn’t actually find any patients who were refused a revision by their insurance company for any reason when their primary procedure failed.

I also consulted with three bariatric surgeons (Billing, Hargroder, Cirangle). Not one would recommend weight gain prior to revision. None expected BMI to be used as a criterion for medical necessity.

What’s more, Regence has already acknowledged medical necessity by covering the removal of the gastric band. As per common bariatric revision policy and medical standards, revision of the failed primary bariatric procedure should have included both repair and reintroduction of gastric restriction. In my case, both procedures were planned as a single surgery. Unfortunately, the surgery plan had to be modified a few days before it was scheduled. Against the medical opinion of my surgeon, Regence dictated that only half of the revision was to be performed. Regence already established medical necessity for a revision; they shouldn’t be allowed to claim later that medical necessity doesn’t exist.

When we made the decision to appeal the denial to the OPM I was initially relieved. Like most Federal employees and their families, I viewed the OPM as my health care champion -- a team able to provide fair and speedy review of my claim against medical standards and insurance policies. It would never have occurred to me that I would be asked to regain all of the weight I’d lost from my first surgery, to actually weigh more than I did before the initial surgery and more than I ever have in my life, before I would be considered for the second half of the revision. And I certainly didn’t expect the 60 day appeals process to take seven months.

My health, weight and well-being have been impacted by the failure of my gastric band and the 13 months I’ve spent pursuing appeals. On all counts I meet the requirements of medically necessity applied to bariatric surgery revision by most insurers in the United States. I was diagnosed with morbid obesity and received covered treatment in the form of a gastric band. Regence has already acknowledged the failure of the gastric band and medical necessity for a revision. The lap band provided gastric restriction until it failed and was removed. My revision cannot be considered complete without restoration of gastric restriction with a vertical sleeve gastrectomy.

Respectfully, I ask that my claim be approved immediately so that the procedure can be performed without further delay. It makes little sense to require that I gain an additional 16 pounds in order to qualify. If the OPM chooses to uphold Regence’s denial, my only recourse will be to file a lawsuit in Federal court. This drastic measure seems completely unnecessary given the facts of the case. A lawsuit would be a poor use of OPM time and taxpayer dollars. All I want, all I’ve ever wanted, is a revision that would repair the damage done by the failed lap band and restore the gastric restriction that I was originally approved for. Please help me bring this case to a quick and satisfactory conclusion.

Respectfully,
Britt Udy


Appendix – Example Bariatric Revision Policies

Example 1 – Aetna Bariatric Revision Policy

Aetna considers repeat bariatric surgery medically necessary for members whose initial bariatric surgery was medically necessary (i.e., who met medical necessity criteria for their initial bariatric surgery), and who meet either of the following medical necessity criteria:

· Conversion to a RYGB or BPD/DS may be considered medically necessary for members who have not had adequate success (defined as loss of more than 50 percent of excess body weight) two years following the primary bariatric surgery procedure and the member has been compliant with a prescribed nutrition and exercise program following the procedure; OR
· Revision of a primary bariatric surgery procedure that has failed due to dilation of the gastric pouch is considered medically necessary if the primary procedure was successful in inducing weight loss prior to the pouch dilation, and the member has been compliant with a prescribed nutrition and exercise program following the procedure.

Example 2 – United Healthcare

Revisional surgeries are covered for patients who have had previous surgical treatment for morbid obesity if the patient had previously met the medical necessity indications at the time of the initial surgery.

Example 3 – ODS Healthplan

Reoperation and Surgical Revision:
Surgical revision may be considered medically necessary when a patient develops complications
from the original surgery (i.e. stricture or obstruction). Medical and surgical complications may
be covered if determined to be medically necessary even if the original surgery was not a covered
benefit.

Example 4 – University of Pittsburgh Medical Center

Repeat or revision bariatric surgery is considered medically necessary for any of the following:
1. To correct complications from surgery such as obstructions or strictures, OR
2. When the primary procedure has failed due to dilation of the gastric pouch, AND
If the primary procedure was successful in inducing weight loss prior to the pouch
dilation, AND The member has been compliant with the prescribed nutrition and exercise
Program.

Example 5 – Blue Care of Michigan

Previous gastric restrictive procedures that have failed for anatomic or technical reasons (for example, obstruction, staple dehiscence, etc.) are determined to be medically appropriate for revision without consideration of the criteria outlined here [ed. note: referring to weight criteria].

Example 6 – WellCare Health Plans

Repeat bariatric surgery is considered medically necessary under the following condition ONLY:
1. A complication has occurred associated with the original procedure

Example 7 – BCBS of Tennessee

Bariatric surgery, for the treatment of morbidly obese individuals 18 years or older, is considered medically appropriate if ANY ONE of the following criteria are met:

An individual who has had a prior bariatric surgical procedure and is requesting / requiring a revision, alteration or reversal must have a related medical or surgical complication of that procedure that is documented by the physician.