Re: Draft Response to Aetna CPB #157

[Guest guest]

Thanks for sharing. We are fighting Aetna as well (I already had my

surgery) and we'll let you know if we come up with anything else. We

already sent a certified letter stating they must send us all paper

work, etc. that they used to deny us. It's a law they have to do it

within 30 days or they get fined. We're going to pin them down.

Donna

> To all Aetna people and those with other insurance companies

denying

> coverage for the BPD/DS based on it being " investigational " : I have

> prepared a counter response. I just had my consultation and am

> hoping to get approved, but I am so outraged the Aetna, Blue

> Cross/Blue Shield, and United Healthcare are denying coverage on

this

> basis that I have put together a formal response.

>

> You can find Aetna's policy bulliten #157 at:

>

> http://www.aetnaushc.com/cpb/data/CPBA0157.html

>

> Please feel free to comment, as this is a draft response:

>

> Hull

>

> Dear Aetna,

>

>

> Regarding the biliopancreatic diversion with duodenal switch

(BPD/DS)

> procedure being " investigational " . As I understand it, a procedure

> is investigational if it is not proven to be both safe and

> effective. I will deal with the efficacy issue first.

>

> You own policy bulletin #157 admits that the BPD/DS is

> effective: " this procedure is reported to have a higher rate of

> weight loss " . In addition, all of the seven references included

> report equal or better weight loss with the BPD/DS procedure when

> compared to the standard Rouy-n-Y (RNY) gastric bypass. Results of

> the BPD procedure without DS have shown no weight regain even out

to

> 20 years [1]. So the efficacy of the BPD and BPD/DS procedures

> cannot be questioned.

>

> Regarding the safety of the procedure, I believe that much of the

> information from the sited references is out of date. In your

> policy bulletin it is stated that " There is only a 50 cm common

> absorptive alimentary tract. " While this was true with the

original

> Socpinaro procedure, most surgeons use 75-100cm common tracts, and

> this dramatically reduces side effects [2],[5].

>

> It is also stated " … this … is rarely performed in the United

States

> due to the high risk of various metabolic complications. " This is

> incorrect. Currently there are 30 US surgeons performing this

> procedure with 18 performing it as their primary procedure.

> Thousands of BPD/DS procedures are done each year. The metabolic

> complication rates have dropped dramatically now that it is common

> practice to make the alimentary limb length 40-50% of the total

> intestinal length.

>

> Your policy bulletin states that " (the distal RNY procedure)

combines

> the least - desirable features of the gastric bypass with the most

> troublesome aspects of the biliopancreatic diversion " .

> Yet it also states that " Although patients can have increased

> frequency of bowel movements, increased fat in their stools, and

> impaired absorption of vitamins, recent studies have reported good

> results (for the distal RNY). Since it is admitted that the

> most " troublesome " aspects of the BPD/DS procedure are shared by

the

> distal RNY procedure than it follows that if the distal RNY

procedure

> has had good results then so too will the BPD/DS procedure. The

> references show it is indeed the case.

>

> Your reference #12 from the policy bulletin is now 9 years out of

> date. Scopinaro published a paper 3 years ago based on over 2000

> patients. He reports that as more has been learned about BPD, the

> morbidity rates have dropped substantially [1].

>

> Your reference #13 describes a singular case of hepatic failure out

> of thousands of procedures done over the years by Scopinaro,

Marceau,

> Hess et all. While obese patients are at increased risk of liver

> failure under any weight loss surgery, There is no evidence to

> suggest that the rate is higher for the BPD procedure. I believe

> that the concern of some physicians is based on outcomes of a long

> outmoded malabsorption procedure known as JIB. It is clearly

stated

> by Hess that liver failure is not a problem with this procedure [2].

>

>

> Many surgeons when first starting to do the BPD/DS procedure have

> higher morbidity rates initially. However, as they learn the

> procedure, morbidity rates drop dramatically [3],[4]

>

> There now exists a large body of evidence to show that the

> Billiopancreatic diversion (with or without duodenal switch) is

safe

> and effective. Several thousand patients have been reported on

with

> follow-ups as long as 20 years. The author of your policy bulletin

> effectively admits that it is as safe and effective as distal RNY

> (which is an approved procedure) and more effective than proximal

> RNY. Over the last 3 years there have been numerous articles

showing

> the long-term safety and efficacy of this procedure. Those that

> claim otherwise are either confusing the procedure with JIB or are

> unaware of the more recent data.

>

> References:

>

>

> 1. Scopinaro N; Adami GF; Marinari GM; Gianetta E; Traverso E;

> Friedman D; Camerini G; Baschieri G; Simonelli A, Biliopancreatic

> diversion, World J Surg 1998 Sep;22(9):936-46

> 2. Hess DS; Hess DW, Biliopancreatic diversion with a duodenal

> switch, Obes Surg 1998 Jun;8(3):267-82

> 3. Baltasar A; del Rio J; Escriva C; Arlandis F; ez R;

> Serra C, Preliminary results of the duodenal switch, Obes Surg 1997

> Dec;7(6):500-4

> 4. Baltasar A; Bou R; Bengochea M; Arlandis F; Escriva C; Mir J;

> ez R; N, Duodenal switch: an effective therapy for

morbid

> obesity--intermediate results, Obes Surg 2001 Feb;11(1):54-8

> 5. Marceau P; Hould FS; Simard S; Lebel S; Bourque RA; Potvin M;

> Biron S, Biliopancreatic diversion with duodenal switch, World J

Surg

> 1998 Sep;22(9):947-54

> 6. Marceau P; Hould FS; Potvin M; Lebel S; Biron S,

> Biliopancreatic diversion (doudenal switch procedure), Eur J

> Gastroenterol Hepatol 1999 Feb;11(2):99-103

> 7. Rabkin RA et all, Distal gastric bypass/duodenal switch

> procedure, Roux-en-Y gastric bypass and biliopancreatic diversion

in

> a community practice, Obes Surg 1998 Feb;8(1):53-9

[Guest guest]

Thanks for sharing. We are fighting Aetna as well (I already had my

surgery) and we'll let you know if we come up with anything else. We

already sent a certified letter stating they must send us all paper

work, etc. that they used to deny us. It's a law they have to do it

within 30 days or they get fined. We're going to pin them down.

Donna

> To all Aetna people and those with other insurance companies

denying

> coverage for the BPD/DS based on it being " investigational " : I have

> prepared a counter response. I just had my consultation and am

> hoping to get approved, but I am so outraged the Aetna, Blue

> Cross/Blue Shield, and United Healthcare are denying coverage on

this

> basis that I have put together a formal response.

>

> You can find Aetna's policy bulliten #157 at:

>

> http://www.aetnaushc.com/cpb/data/CPBA0157.html

>

> Please feel free to comment, as this is a draft response:

>

> Hull

>

> Dear Aetna,

>

>

> Regarding the biliopancreatic diversion with duodenal switch

(BPD/DS)

> procedure being " investigational " . As I understand it, a procedure

> is investigational if it is not proven to be both safe and

> effective. I will deal with the efficacy issue first.

>

> You own policy bulletin #157 admits that the BPD/DS is

> effective: " this procedure is reported to have a higher rate of

> weight loss " . In addition, all of the seven references included

> report equal or better weight loss with the BPD/DS procedure when

> compared to the standard Rouy-n-Y (RNY) gastric bypass. Results of

> the BPD procedure without DS have shown no weight regain even out

to

> 20 years [1]. So the efficacy of the BPD and BPD/DS procedures

> cannot be questioned.

>

> Regarding the safety of the procedure, I believe that much of the

> information from the sited references is out of date. In your

> policy bulletin it is stated that " There is only a 50 cm common

> absorptive alimentary tract. " While this was true with the

original

> Socpinaro procedure, most surgeons use 75-100cm common tracts, and

> this dramatically reduces side effects [2],[5].

>

> It is also stated " … this … is rarely performed in the United

States

> due to the high risk of various metabolic complications. " This is

> incorrect. Currently there are 30 US surgeons performing this

> procedure with 18 performing it as their primary procedure.

> Thousands of BPD/DS procedures are done each year. The metabolic

> complication rates have dropped dramatically now that it is common

> practice to make the alimentary limb length 40-50% of the total

> intestinal length.

>

> Your policy bulletin states that " (the distal RNY procedure)

combines

> the least - desirable features of the gastric bypass with the most

> troublesome aspects of the biliopancreatic diversion " .

> Yet it also states that " Although patients can have increased

> frequency of bowel movements, increased fat in their stools, and

> impaired absorption of vitamins, recent studies have reported good

> results (for the distal RNY). Since it is admitted that the

> most " troublesome " aspects of the BPD/DS procedure are shared by

the

> distal RNY procedure than it follows that if the distal RNY

procedure

> has had good results then so too will the BPD/DS procedure. The

> references show it is indeed the case.

>

> Your reference #12 from the policy bulletin is now 9 years out of

> date. Scopinaro published a paper 3 years ago based on over 2000

> patients. He reports that as more has been learned about BPD, the

> morbidity rates have dropped substantially [1].

>

> Your reference #13 describes a singular case of hepatic failure out

> of thousands of procedures done over the years by Scopinaro,

Marceau,

> Hess et all. While obese patients are at increased risk of liver

> failure under any weight loss surgery, There is no evidence to

> suggest that the rate is higher for the BPD procedure. I believe

> that the concern of some physicians is based on outcomes of a long

> outmoded malabsorption procedure known as JIB. It is clearly

stated

> by Hess that liver failure is not a problem with this procedure [2].

>

>

> Many surgeons when first starting to do the BPD/DS procedure have

> higher morbidity rates initially. However, as they learn the

> procedure, morbidity rates drop dramatically [3],[4]

>

> There now exists a large body of evidence to show that the

> Billiopancreatic diversion (with or without duodenal switch) is

safe

> and effective. Several thousand patients have been reported on

with

> follow-ups as long as 20 years. The author of your policy bulletin

> effectively admits that it is as safe and effective as distal RNY

> (which is an approved procedure) and more effective than proximal

> RNY. Over the last 3 years there have been numerous articles

showing

> the long-term safety and efficacy of this procedure. Those that

> claim otherwise are either confusing the procedure with JIB or are

> unaware of the more recent data.

>

> References:

>

>

> 1. Scopinaro N; Adami GF; Marinari GM; Gianetta E; Traverso E;

> Friedman D; Camerini G; Baschieri G; Simonelli A, Biliopancreatic

> diversion, World J Surg 1998 Sep;22(9):936-46

> 2. Hess DS; Hess DW, Biliopancreatic diversion with a duodenal

> switch, Obes Surg 1998 Jun;8(3):267-82

> 3. Baltasar A; del Rio J; Escriva C; Arlandis F; ez R;

> Serra C, Preliminary results of the duodenal switch, Obes Surg 1997

> Dec;7(6):500-4

> 4. Baltasar A; Bou R; Bengochea M; Arlandis F; Escriva C; Mir J;

> ez R; N, Duodenal switch: an effective therapy for

morbid

> obesity--intermediate results, Obes Surg 2001 Feb;11(1):54-8

> 5. Marceau P; Hould FS; Simard S; Lebel S; Bourque RA; Potvin M;

> Biron S, Biliopancreatic diversion with duodenal switch, World J

Surg

> 1998 Sep;22(9):947-54

> 6. Marceau P; Hould FS; Potvin M; Lebel S; Biron S,

> Biliopancreatic diversion (doudenal switch procedure), Eur J

> Gastroenterol Hepatol 1999 Feb;11(2):99-103

> 7. Rabkin RA et all, Distal gastric bypass/duodenal switch

> procedure, Roux-en-Y gastric bypass and biliopancreatic diversion

in

> a community practice, Obes Surg 1998 Feb;8(1):53-9