HERE IS AN APPEAL LETTER THAT DR R. SENT OUT A WHILE BACK

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I HOPE THIS HELPS!!

Calissa

MGB HOPEFUL!

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" Rutledge, M.D., F.A.C.S. " Save Address -

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Re: Re:insurance

Date:

Sat, 4 Nov 2000 22:01:21 -0500

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>Hey, gang....me again.

>I've decided to fight my insurance company's decision to only approve RNY.

>I've been told that if I can put a good case together as to why I should

have

>the MGB instead, I can appeal their decision. The problem is that I'm not

>sure where to start. Has anyone appealed in a similar way?

http://www.clos.net/ins-appeal-personal.htm

Sample Personal Insurance Appeal Letter

One patient sent this letter to her insurance company to obtain

permission to go out of network for surgery with Dr Rutledge. She

volunteered this letter as a model for others to use in their discussions

with their insurance companies.

To: Grievance Department

Insurance Company Name

Somewhere, State 32000

Re:

Member Name: Jane Doe

ID #: XXXXXXXXXXX

Dear Grievance Department:

I very much appreciate Insurance Company Name approval of my request

for payment of services for Laparoscopic Weight Loss Surgery. Unfortunately

there is not a doctor " In Network " that performs the type of surgery that my

personal physician and I want me to have. I respectfully request you

approve The Mini-Gastric Bypass, a laparoscopic procedure performed

exclusively by Dr. Rutledge of The Center for Laparoscopic Obesity

Surgery in Durham, North Carolina. I hope after reviewing the additional

information I am supplying you, you will reconsider your current position,

thus allowing me to move forward to a healthy life.

Personal Physician's name and I have thoroughly researched the

different types of weight loss surgeries. After this extensive research, we

are thoroughly convinced that The Mini-Gastric Bypass, is the safest and

most effective procedure for me. I have also researched many of the

surgeons here in State, plus the ones that you have recommended that are " In

Network " . Although some offer a laparoscopic procedure, I find that their

laparoscopic surgery is not the same procedure as The Mini-Gastric Bypass at

all. Name of Surgeon and Name of Surgeon, the only two " In Network "

surgeons that perform laparoscopic weight loss surgery, offer a Laparoscopic

Roux-en-Y which is quite different from The Mini-Gastric Bypass. (Please

refer to attachments Exhibits A - MGB Procedure & B RNY Diagram & Patient

Education Manual for the Mini-Gastric Bypass - Pages 10-17 describing the

two different types of surgery.)

I realize you may have a contract for services with other providers

(Physicians) in Insurance Company's of State's area that perform Bariatric,

weight loss, surgery. Just as these surgeons have a contract with you, I

would assume you in turn have an obligation to them to provide patients to

them that require procedures that they perform. Possibly, I am only

guessing, that if you were to allow me to go " out of network " to another

surgeon for a procedure that an " in network " surgeon performs and the " in

network " surgeon became aware of this, there could be a problem. I

understand that contracts have to work both ways.

If this is an issue with respect to Dr. Rutledge being approved to

perform the Mini-Gastric Bypass, we don't have a problem after all. Section

9.4 Referral Health Services Rendered by Non-Participating Providers states

(Exhibit " In the event that SPECIFIC Health Services cannot be provided

by or through a participating provider, you are eligible for coverage of

eligible expenses for medically necessary health services obtained through

non-participating providers. "

The Mini-Gastric Bypass is a SPECIFIC procedure that was developed by

Dr. Rutledge. It is not offered by either of the " in network " doctors. The

following table outlines the main differences and reasons why Personal

Physician's name and I want Dr. Rutledge to perform my surgery.

Simply, the benefits of the Mini-Gastric Bypass, not to mention the

costs, are not available in network.

Doctor Comparison

My Doctor's & My Surgeon of Choice

Insurance Company Name of State's In Network Surgeons

Dr. Rutledge, M.D. F.A.C.S.

Name of Surgeon

M. D.

Name of Surgeon, M.D.

Type Surgery Offered

Laparoscopic Mini-Gastric Bypass

Laparoscopic Roux-en-Y

Laparoscopic Roux-en-Y

Uses a " Gastric Tube " (1)

Uses a small gastric pouch

Uses a small gastric pouch

Uses a " Loop " Intestinal Bypass (2)

(The Billroth II)

Uses a Roux-en-Y

Uses a Roux-en-Y

NG Tube,

Foley catheter Abdominal drain

No

Yes

Yes

Number Surgeries Performed

Over 385 Mini-Gastric Bypasses

Approximately 15 Laparoscopic Roux-en-Y's

Approximately 6 Laparoscopic Roux-en-Y's

Average Hospitalization

1-2 Nights (> 60% of recent cases stay only 1 night)

4 Nights

4 -6 Nights

Cost of Surgery

$13,000 to $16,000 (less with shorter stay)

$27,000 +/-

$27,000 to $37,000 +/-

Typical Recovery Time (Back to Work)

Approx. 1 to 2 weeks

Approx. 6 weeks

Approx. 6 weeks

Automatically Remove Gallbladder (3)

NO

YES

YES

Mortalities

NO Hospital, 30 day, 60 day or 180 day mortality

??

YES

Reversibility of Surgery (4)

YES (Laparoscopically)

Extremely difficult & dangerous

Extremely difficult & dangerous

Average Operating Time (5)

Latest surgeries have been approx. 30 - 60 minutes (less complications

from Anesthesia)

Approx. 4 - 6 hours

Approx. 4 - 6 hours

(1) Benefit of " Gastric Tube " The long gastric tube is used instead

of the small pouch in the standard gastric bypass to keep the operation away

from the esophagus and to make pulling the intestine to the stomach safer

and easier.

(2) Benefit of a " Loop " Intestinal Bypass. The Mini-Gastric Bypass

uses a loop of small intestine (The Billroth II) to avoid cutting and

sewing the bowel in more than one place. This simplifies and shortens the

operation and makes it safer.

(3) In the MGB patients with the safe and controlled weight loss and

the relatively normal digestion that occurs after the surgery, Dr. Rutledge

has never had the high rates of gallbladder disease seen by others. Since

the availability of Actigall, a drug that helps dissolve gallstones, he has

minimal gallbladder disease.

(4) Re-operation is easier => If you need to operate upon the

connection between the stomach and the intestine, it is easy in the

Mini-Gastric Bypass because it is up near the front of the abdomen. The

connection between the stomach and the intestine in Roux-en-Y operations is

high in the abdomen and deep at the back of the abdomen making it much

harder and more dangerous to operate upon.

(5) Short operating time => less tissue trauma - means less pooling of

blood in the legs and less risk of clots

PLEASE NOTE - One Dr's assistant, he prefers to perform the Open RNY.

His Laparoscopic surgery takes twice as long and he charges $2,000 more

than for the Open RNY.

Additional Reasons for the Mini-Gastric Bypass :

Ø No silicone or plastic foreign body left in the body as in the

Lap Band => less risk of erosion, perforation and stricture

Ø Not like the Duodenal Switch. No Stomach is cut out. The

Mini-Gastric Bypass is easily reversed laparoscopically

Ø The Mini-Gastric Bypass has a long narrow gastric pouch not a

small pouch like many Roux-en-Y procedures or VBG operations => Allows

patients to eat a more normal diet.

Ø The long gastric pouch means that after surgery you can eat

more and feel more comfortable. You can eat more like normal. You will

have less nausea and vomiting because of the bigger pouch.

Ø Large connection between the stomach and small bowel

(anastomosis) not a small one => Less chance of stricture causing nausea and

vomiting and requiring surgery.

Ø The long gastric pouch puts the connection between the stomach

pouch and the small bowel in a place that puts less stretch on the small

bowel.

Ø Long gastric pouch => no risk of bile reflux esophagitis.

Ø Easy to lengthen the bypass and narrow the pouch => good if you

regain your weight

Ø Not like the Old Loop Gastric Bypass

Ø Billroth II (Loop) Gastrojejunostomy (connection between the

stomach and the small bowel) not Roux-en-Y => most widely selected method of

stomach to small connection chosen by American surgeons

.

Ø No part of the stomach is cut out => it is there if you need

it, less chance of injury to the spleen, less risk of bleeding

Dr. Rutledge is a Insurance Company Name provider in North Carolina

and has performed the Mini-Gastric Bypass on several Insurance Company Name

patients from throughout the country. His credentials are impeccable. He

has chosen to specialize in the treatment of the obese and this is the only

surgery he performs. To date he has performed over 360 Mini-Gastric

Bypasses, not just a few Laparoscopic Roux-en-Y's like the State providers.

He has had zero Hospital, 30 day, 60 day and 180 day mortality rates and

6.5% morbidity rates. I understand this is not the case with some State

providers.

There is a very important point I need to bring to your attention.

My family history strongly suggests that I am destined to be a

diabetic with heart problems. Morbid obesity runs rampant throughout my

Father's side of the family. My father and every one of his siblings and

his parents all were morbidly obese and died of the complications. This was

not a quick death that they each experienced, but a very slow one. They

each suffered with many of the consequences of obesity; blown out knees, bad

heart, diabetes, etc., etc. Their medical expenses were horrendous. I

never thought that I would be in their same position. Most of my adult

life, until the age of 35, I fluctuated between 135 and 160 pounds. I am

between 5' 9 " and 5'10 " . I thought I was obese if I weighed 175 pounds. My

highest weight up until that time was when I gave birth to our 10 lb. 6 oz.

son. At the time of our son's birth, I was a whopping 235 lbs. Six months

later I was back down to 175 pounds when I had to have a hysterectomy. Over

the following years I have been progressively losing the genetic battle.

Since my visit to Name of Surgeon, a local Bariatric surgeon, for a

fact finding consultation on weight loss surgery in September 99, I find

that my health is continuing to deteriorate. I am now 275 pounds. That

means at my height, which is between 5'9 " and 5'10 " , I am approximately 130

pounds overweight, with a BMI of 40. My quality of life is deteriorating to

the point that I do very little. I do not have the physical stamina to

exercise or interact with my family and friends. My increasing physical

ailments make walking extremely difficult and painful. During the last

couple of years the following physical problems I am experiencing, I

believe, are attributable to morbid obesity:

Ø Upper and lower back pain

Ø Pain in my hips, knees, ankles and feet

Ø Shortness of breath even upon minor exertion

Ø Acid reflux

Ø Urinary incontinence

Ø Rashes and skin infections

Ø Poor sleep patterns

Ø Chronic Fatigue (I can barely get out of bed in the morning)

Ø Depression

My research tells me that Morbid Obesity is a progressive disease in

which heredity plays an integral role. Due to my heredity from my father, I

face certain additional co-morbidities. My genetics and morbid obesity put

me at an increased risk of heart disease, hypertension, diabetes, stroke,

organ failure and cancer, specifically breast cancer.

As a typical morbidly obese person, I have tried numerous weight loss

programs, un-supervised and supervised. No diet program, even in

conjunction with drug therapy has worked well to produce significant

sustained weight loss. Repeated attempts to diet have resulted in failure,

leading to frustration with feelings of guilt and inadequacy.

Some of the diet programs that I have tried are Weight Watchers, basic

calorie counting with appetite suppressants, the Atkins Diet, Eat 4 Your

Blood Type, hypnosis, Phen/Fen, OTC diet pills, and WellFast (a medically

supervised liquid protein diet accompanied by private counseling, weekly

support meetings and personal trainer). I went through the Wellfast

program two different times, at tremendous expense. (The first WellFast

program netted a goal weight of 135 lbs. Soon I started regaining the

weight till I was heavier than when I started. I tried the program again a

couple of years ago and just couldn't do it. Needless to say I was

completely demoralized by this failure.)

I have not attempted to conquer excess weight with diet alone. I have

hired personal trainers, paid for expensive health club memberships, and I

own several pieces of workout/gym equipment. All attempts have proven to be

unsuccessful in providing long-term results.

Based on my history of persistent weight gain, I am afraid I will

continue to gain weight and in time become sicker and die of complications

of morbid obesity -- just like my father, his sisters, and his mother and

father. The continued deterioration of my health and damage caused by my

morbid obesity are statistical certainties. That is why I want and need to

have the Mini-Gastric Bypass..

I believe surgical treatment is medically necessary because it is the

only proven method of achieving long term weight control for the severely

obese. Bariatric surgery involves reducing the size of the gastric

reservoir, with or without a degree of associated malabsorbtion. Eating

behavior improves dramatically. This reduces caloric intake and ensures

that the patient practices behavior modification. Success of surgical

treatment must begin with realistic goals and progress through the best

possible use of well-designed and tested operations.

I have interacted with many of Dr. Rutledge's patients. I find that

after they have had the Mini-Gastric Bypass surgery, their co-morbidities

such as glucose intolerance and diabetes mellitus, sleep apnea, high

cholesterol, and hypertension are alleviated, not to mention they have

improved mobility and stamina. They also note a better mood, self esteem,

interpersonal effectiveness and an enhanced quality of life. They are

losing weight. They have found " Hope " .

Not only is gastric bypass surgery an effective means of treating

obesity, it will cost you more in the long-run not to cover this type of

procedure. Preventing and treating obesity could reduce U.S. Healthcare

costs by between 25% -44% according to a report in the March 9th issue of

Archives of Internal Medicine, a journal of the American Medical

Association. These costs were reflected in increasing out-patient hospital

visits (24% higher in severely obese), in hospital stays (74% higher in

severely obese patients) and pharmacy costs (78% higher in severely obese

patients) as BMI increased from normal to severely obese.

Surgery will cost a significantly smaller amount of money compared to

my future needs if I continue to carry this weight. Without the

intervention of the Mini-Gastric Bypass, future complications that may be

presented to your company may include:

· Heart Disease, Including Heart Attack,

· Stroke

· Diabetes

· Knee Replacement

· Hip Surgery

· Gall Bladder Surgery

· More aggressive GERD (Acid Reflux) treatment, up to and

including Surgery

· Breast reduction

I have researched weight loss surgery for countless hours. I have

communicated with many patients and am fully informed of the possible

complications, including,

§ Allergic Reactions,

§ Anesthetic Complications

§ Bleeding

§ Blood Clots

§ Infection

§ Leak

· Ulcer or Strictures

· Dumping Syndrome

· Bowel Obstruction

· Laparoscopic Related Surgery Risks

· Side Effects of Drugs,

· Loss of Bodily Function, including Stroke, Heart Attack, Limb

Loss and other

· problems related to surgery and anesthesia,

· Risks from Transfusions

· Vitamin and Mineral Deficiencies

· Death.

Laparoscopic gastric bypass surgery has marked advantages over an open

procedure, i.e.,

Ø Less invasive,

Ø Shorter surgical time

Ø Shorter hospital stay

Ø Quicker return to normal activities

Ø Quicker return to work

Ø Able to exercise sooner

Ø Size of incision

Ø Length of time patient is on pain medication

Ø Lower probability of complications from extended period under

general anesthesia

Especially of concern to me when researching the gastric bypass

surgery was the fact 20-30% of all patients who submit to the open procedure

have further incisional complications including, but not limited to

hernia(s), requiring additional surgery. Both of the " In Network " doctors

prefer to perform the open procedure.

The bottom line, is that to minimize the possible risks, I want the

Laparoscopic Mini-Gastric Bypass. I feel it is the safest possible approach

to solving the problem of my obesity. The following summarizes the reasons

for choosing Dr. Rutledge:

Ø Dr. Rutledge's patient information and education requirements

are clearly superior. (See attached Patient Manual (Exhibit C) for your

review. Please take particular note of Page 6 of the Patient Manual. This

is the acceptance criteria patients of Dr. Rutledge have to comply with in

order to obtain approval by him for his procedure.)

Ø Dr. Rutledge's patient satisfaction and success level is

clearly quite impressive. (I have spoken, met and corresponded with many of

his patients, and patients with the other different types of procedures.

Ø Dr. Rutledge does not remove the gall bladder unless medically

indicated as necessary. Rather he chooses to treat the strain of the rapid

weight loss on the gall bladder with medication and monitoring. Thus not

adding unnecessary stress to the body.

Ø Dr. Rutledge is the only physician who addressed the additional

stress of obesity in and of itself on the liver. None further gave

consideration of the compounded stress placed on the liver when required to

metabolize alcohol.

Ø Dr. Rutledge was the only physician who required written

documented letters of

§ familial support.

§ primary care physician's support.

§ exercise program and gym member ship.

Ø Dr. Rutledge has chosen to specialize in the treatment of

obesity exclusively. He performs only the Laparoscopic Mini-Gastric Bypass.

After over 360 successful procedures, I feel confident in his skills.

Ø Finally, the cost to United Healthcare is markedly lower. Dr.

Rutledge's Mini-Gastric Bypass will cost approximately $15,000 to $18,000

compared to the " In Network " Laparoscopic Roux-en-Y which will cost

approximately $27,000 to $37,000.

I know that Insurance Company Name is sympathetic to my plight and

others who suffer from genetic obesity. I have recently learned of other

cases that Insurance Company Name provided medical expense coverage for

their Mini-Gastric Bypass by Dr. Rutledge. Many as you will note were " Out

of Network " .

A Partial Listing of Dr. Rutledge Patients

with One Insurance Company

Date of Surgery

Name of Patient

10/27/99

10/18/99

Brown

10/7/99

Wanda Rhiner Fuquay

10/4/99

Carlissa

9/21/99

Myer

8/26/99

8/16/99

Christy

7/18/99

Willard Jeffries

7/14/99

Sheron

6/1/99

Kathy Thorstad

5/25/99

5/24/99

Culp (Select Plus POS)

5/14/99

Clapp

4/26/99`

Janet Stone

2/23/99

Tina Ketterman

1/11/99

Natasha Chambers

12/28/98

Nan Coulter

12/16/98

Cerce Starnes

I am sure you will agree that I have put a great deal of time and

effort into my decision to have weight loss surgery -- more specifically the

Mini-Gastric Bypass by Dr. Rutledge. Given my 15 years of failed diet

attempts, my current status as clinically morbidly obese, my many

co-morbidities and related familial history, I am confident that I am an

ideal candidate for your pre-authorization of The Mini-Gastric Bypass

procedure by Dr. Rutledge.

As time is of the essence for medical, financial and scheduling

reasons, I look forward to an expeditious response. I thank you for your

time, consideration and assistance with this matter.

Sincerely,

Your Name

Enclosures - Letter from personal physician - Personal

Physician's name

Physician Profile - Dr. Rutledge

Preop Evaluation

Synopsis of New England Journal of Medicine Study re: Genetic Basis of

Obesity

Patient Education Manual for the Mini-Gastric

Bypass

Exhibit A - Description of the Mini-Gastric

Procedure

Exhibit B - Roux-en-Y Diagram

Exhibit C - Insurance Company Name Manual Section ___ - Section ___

and ____

RR

Rutledge, M.D., F.A.C.S.

The Center for Laparoscopic Obesity Surgery

4301 Ben lin Blvd.

Durham, N.C. 27704

Telephone #:

Fax #:

Email: DrR@...

************************************************

Please Visit our Web site: http://clos.net

************************************************

Please join the

Mini-Gastric Bypass Community at

http://clos.net/forms/mailinglist_form.htm

Get the Mini-Gastric Bypass

Patient Education Manual

http://www.clos.net/get_patient_manual.htm

Re:insurance

>Hey, gang....me again.

>I've decided to fight my insurance company's decision to only approve RNY.

>I've been told that if I can put a good case together as to why I should

have

>the MGB instead, I can appeal their decision. The problem is that I'm not

>sure where to start. Has anyone appealed in a similar way? I've read so

>much about the RNY and know the stats (as far as a slightly higher

>complication rate, much longer hospital stay, etc.) but can't even begin

to

>know where I found them.

>If anyone can help me put together the goods, I will definitely give you a

%

>of the 'earnings' of the reimbursement....I'm serious!!

>Please help! I'm kind of overwhelmed with getting ready for the

>surgery....less than 2 weeks away...and all, but need to get this to

>insurance ASAP.

>

>Thanks!!

>

>

>

>