| June 2, 2003 ATTN: Cigna HealthCare - Intracorp PO Box 182223 Chattanooga, TN 37422-7223 Re: Brian McNamara SprintChoice HealthCare - PPO Policy # Dear Sir/Madam: My name is Brian McNamara, I weigh 466 lbs. and I am morbidly obese, in this letter I want to talk to you about my health not my weight. I would like to tell you more about my morbid obesity, my laparoscopic-gastric bypass, and myself. I am writing this letter with the hope that Insurance Company will BE FIRMLY CONVINCED that there is a medical necessity IN PROVIDING ME WITH THIS LIFE SAVING SURGERY and that I HAVE very serious underlying medical conditions that will be mitigated or eliminated by said surgery. Patients who have weight loss surgery generally lose two-thirds of their excess weight within 2 years. I hope to lose over 250 in the first year. Imagine going from nearly 466 pounds to 216 pounds, weight loss of this kind is not only possible but is considered typical of this kind of surgical procedure, that weight loss will be only a by-product of this surgery. The primary benefits from this surgery are limitless they will cure/mitigate: pain and fatigue, possible sleep apnea, hypertension, and associated cardiac risks. This surgery will certainly decrease my back and leg pains, there by allowing me to become physically active again and regain my physical mobility; the preceding changes will surely improve or cure my depression. Finally, my Gastro-Esophageal Reflux Disease will be cured or significantly decreased. Without this surgery and improvement of my co-morbid conditions, I will be doomed to living what time I have left in pain and decreasing mobility. Ultimately I will die without living a normal life span due to my disease of morbid obesity, and the complications of my medical conditions. All of which could have been mitigated and/or eliminated by approval of this surgery for me. I am currently experiencing several severe co-morbid conditions that affect my health and lifestyle in a negative manner. These conditions are listed as follows: chronic low back and knee pain, arthritis, leg pains, sleep apnea, restless sleep patterns, shortness of breath on exertion, racing heartbeat with activity, chronic fatigue, asthma and gastro-esophageal reflux disease. All of these problems can be directly attributed to the disease of Morbid Obesity. * Chronic back pain The entire weight of the upper body falls on the base of the spine, and overweight causes it to wear out, or to fail. The consequence is accelerated arthritis of the spine, or "slipped disk", when the cartilage between the vertebrae squeezes out. Either of these conditions can cause irritation or compression of the nerve roots, and lead to sciatica - a dull, intense pain down the outside of the leg. * Chronic fatigue Having to carry around so much excess weight each day leaves an obese person with very little energy for much else. Routine tasks such as walking, shopping, and working in the Las Vegas heat are often put off or neglected. Severely overweight people are unable to participate in recreational activities with family and friends, and can only watch from the sidelines due to their physical limitations. Imagine trying to perform your daily activities with a 25Olb. Weight tied to your back. These are the challenges morbidly obese people face each and every day AND I AM LOSING THIS BATTLE. * Respiratory insufficiency/Asthma Obese persons find that exercise causes them to be out of breath very quickly. The lungs are decreased in size, and the chest wall is very heavy and difficult to lift. At the same time, the demand for oxygen is greater, with any physical activity. These conditions prevents normal physical activities and exercise, often interferes with usual daily activities, such as shopping, yard-work, or stair climbing, and can be completely disabling. I am short of breath, unable to breathe and feel like my weight is suffocating me. * Persistent joint pain The body parts that bear most of the weight are: hips, knees, ankles and feet. These joints tend to wear out more quickly, or to develop degenerative arthritis much earlier and more frequently, than in the normal-weighted person. Eventually, joint replacement surgery may be needed, to relieve the severe pain. Unfortunately, the obese person faces a disadvantage there too. Expensive joint replacement has much poorer results in the obese and can often be prevented by simply helping the patient lose weight, which this surgery does accomplish. Many orthopedic surgeons refuse to perform the surgery in severely overweight patients, because these patients are at a greater risk for immobility complications because of the weight stress to the new joint. The decreased mobility of joint pain leads to a sedentary life style, which leads to further weight gain. *Sleep Apnea The Greek word "apnea" literally means "without breath." People with untreated sleep apnea stop breathing repeatedly during their sleep, sometimes hundreds of times during the night and often for a minute or longer. Obstructive sleep apnea is caused by a blockage of the airway, usually when the soft tissue in the rear of the throat collapses and closes during sleep. With each apnea event, the brain briefly arouses sleep apnea victims from sleep in order for them to resume breathing, but consequently sleep is extremely fragmented and of poor quality. Risk factors include being overweight, and over the age of forty. Sleep Apnea is a serious disorder can have significant consequences. Untreated, sleep apnea can cause high blood pressure and other disease, memory problems, weight gain, impotency, and headaches. Moreover, untreated sleep apnea may be responsible for job impairment and motor vehicle crashes. I have sleep apnea and this is serious enough to cause my death. Sleep Apnea almost always disappears when the morbidly obese individual loses weight, which again this surgery will accomplish. Source: American Sleep Apnea Association. Since 1996 I have been required to use CPAP machine for sleep apnea. I have mobility issues and constraints that are due to my weight. At night, my arms, legs, and other body parts experience numbness and I am told that this is due to the pressure on my nerves. I do know that these conditions cause me pain, a pain that can be alleviated through reduction in body mass, which can be achieved through gastric surgery. Overweight persons are 10 times as likely to develop Type II, Adult-Onset Diabetes. Elevation of the blood sugar leads to damage to tissues throughout the body. Diabetes is the leading cause of adult-onset blindness, a major cause of kidney failure, and the cause of over one half of all amputations. It is the #3 cause of death in the United States. As a result of my morbid obesity, I am a prime candidate for Type 2, Adult-Onset Diabetes. It has been documented that all of these diseases can be significantly reduced or eradicated by weight loss. While I suffer from many co-morbid conditions caused by obesity, I do not wish to wait until I become completely bedridden before taking action to improve my health and prolong my life. I am not seeking a cosmetic fix-all for my weight problem. I am asking for help in controlling a disease that will only cause further health problems and eventually death. Let me assure you I do not see gastric surgery as a panacea that will fix all my problems or even all my health issues, but rather as a tool to use successfully to improve my quality of life and health, and eliminate or mitigate my co-morbid conditions. As per Dr. Samuel Klein, an official of the North American Association for the Study of Obesity (NAASO) and Professor of Medicine at Washington University School of Medicine in St. Louis. "When performed by experienced surgeons on appropriately selected patients, surgery is an effective method for weight loss and treating the medical complications of obesity. Moreover, recent data demonstrate that surgery can even prevent the onset of diabetes, high blood pressure and other life-threatening disorders in these patients." As of May 2, 2003 I weighed 466 pounds (250 lbs. overweight) and have a BMI of 58.2. I am considered by the medical community to be severely morbidly obese. Morbid obesity is defined by a patient having a BMII of at least 40 and/or weighing at least 100 pounds over the ideal body weight or more than twice the normal weight for height. I am currently more than 2 times that. No one at this size can be living a healthy life including myself. Improvements in the surgical correction of morbid obesity have allowed increasing numbers of morbidly obese patients to undergo successful and sustained weight loss, drastically improving their health, which lowers the cost of health care for life. In the past, I have tried many, professionally supervised, diets, exercise programs, and weight loss medications, and (see attached DIET HISTORY). Although some of them caused some weight loss, I always regained that weight, along with significant additional weight. Of those who initially succeed with dieting, most regain the weight they have lost and more! Commonly the "cure" rate for morbid obesity is less than 5% with non-surgical methods. These statistics are quoted from the National Institute of Health Guidelines and have proven to be true in my case. I have tried commercial diets as well, such as Jenny Craig, Cambridge diet, Slim Fast, Herbalife, Gold’s Gym, Dexatrim, and pre-packaged food plans. With all of these diets each one of them have been reviewed with my primary care doctor’s prior to or during each attempt with a weight loss program. One of the recent programs with Slim fast was discourage by my PCP due to sugar content it and was recommended to do a low carbohydrate diet or the Atkins program during September 02 – March 03. None have proved to be an effective weight loss method. I am within the 95% where dieting has not produced or maintained a significant and beneficial weight loss making me a prime candidate for surgery. Based on my history of uncontrollable and persistent weight gain, I will continue to gain weight and in time, become sicker. I am frustrated and depressed over my past efforts to keep the weight off. My doctor’s and I feel as though I have exhausted every other weight loss method without success and that surgery is the next and final step in permanent weight loss for me. Gastric surgery is an effective method of PERMANENT weight loss. Operative procedures are designed for severely obese patients who have attempted medical management of their obesity but have been unsuccessful in achieving permanent weight loss. Gastric Restrictive Procedures, along with other methods of surgical treatment of obesity, is broadly recognized as a safe, effective, and cost effective method of weight loss for morbidly obese patients. The National Institute of Health released a consensus statement supporting Weight loss Surgery as an approved procedure that states, "A gastric restrictive or bypass procedure should be considered only for well-informed and motivated patients with acceptable operative risks. The patient should be able to participate in treatment and long-term follow-up. Patients whose BMI exceeds 40 are potential candidates for surgery if they strongly desire substantial weight loss, because obesity severely impairs the quality of Their lives.” I have thoroughly researched my intended surgery, and I am keenly aware of the risks involved. I am also aware that the long-term benefits far outweigh those risks, and I wish to proceed. I am very fortunate to have a large network of family and friends, as well as my physician and Surgical Weight Loss Center who support my decision for surgery, and are committed to assisting me with after-care. I have already joined a support group and regularly participate in discussions with other morbidly obese people who have had, or will have weight loss surgery. This group has been and will continue to be tremendously beneficial in providing me with first-hand information on all aspects of surgery pre and post op. There is not one person who is post op, which has not reported an improvement in the quality of their lives. Surgical means to begin the weight reduction process is my only option. It is a tool that I will use and as the weight starts coming off, I will be able to begin the exercise I need in order to make this procedure successful. I can once again have and live a healthy life. I know this is how it works and what I will have to do. I want to do the only thing that has any measurable amount of success and as you know the success rate for bariatric surgery is very high. I know it is not a catchall thing and I will have to work to lose the amount of weight I need to be healthy. I have experienced some form of obesity most of my adult life. I live in fear of my health deteriorating further to the point I will be bedridden and or require physical therapy and knee replacement surgeries. These surgeries would probably be UNNECESSARY if I have a weight loss procedure. It has been shown that the gastric surgery will be a more cost effective way of treating all these conditions than to have to have them treated by drugs and other surgical techniques and interventions. It has been indicated that diabetes, heart disease, an increased risk of cancer and death are in my near future. It is only a matter of time before these affect my health more severely than they do already. In my opinion, having surgery is protecting my life. The National Institute of Health supports obesity surgery, along with following individuals and organizations: Milliman and Robertson Healthcare Management Guidelines Former U.S. Surgeon General C. Everett Koop, M.D. American Association of Clinical Endocrinologists Mayo Clinic Johns Hopkins Medical Center American Diabetic Association American Society for Bariatric Surgery The New England Journal of Medicine The following is a list of enclosures included with this letter 1. Cigna guideline discrepancies 2. Supporting letter from my Bariatric physician with previous documentation, 3. Letter and records from my primary care physician, 4. Past diet program list, PCP records, Kaiser records, Military records, Jenny Craig, Gold’s gym 5. Cardiovascular Records 6. Pulmonary Records 7. Orthopedic Surgery Records 8. Sleep Study Test I know that if your were in my position you would write exactly the letter I have before you, if I were in your position I would approve the surgery based on the medical need of the patient. You would want to save your life as much as I want to save mine. I am a Son, a Father, a Grandfather, a friend, and a human being. My life is valuable not only to me but also to those around me. Please contact me should you have any further questions or requests for information. I look forward to a prompt response to my request for Gastric surgery, as I am eager to make this life saving change! Sincerely, Brian McNamara |
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