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Surgeon: Dr. Emma Patterson, Portland, OR
Surgery date: October 22, 2001
Pre-op weight/BMI: 261/44
Current weight/BMI: 233 (as of November 21, 2001)
Personal web page: See my AMOS Profile page

by Lee Anne:

These are the notes that I used for a conference call that I had with the grievance committee of my insurance on August 16th.

“I would like to explain the processes that I have gone through and then go over the criteria for this surgery. I’ll probably talk fast because I have lots to talk about.

1. PROCESSES
Around the time Carnie Wilson was in People Magazine about her gastric bypass surgery, I went to the Cigna web site to inquire about coverage. I ended up sending an email to inquiries@cigna.com. I faxed the email that I sent and the response (response dated February 13th) I received yesterday. I was thrilled and depressed because I met the qualifications. Because I believed that I met the qualifications, I made an appointment with my doctor, Dr. Rebekah Trochmann on the 26th of February. She agreed that I was a good candidate for the surgery and that it was the best solution. She submitted for preauthorization. The referral number 283052. I called Dr. Swanstrom/Dr. Patterson’s office and they sent an application packet, which I filled out and returned. Shortly thereafter, I received a letter that instructed me to get a psychological evaluation and have a dietician counseling session. I met with Dr. Robert Poole and Dee Sandquist on March 15th. Their letters and/or dictation were a part of the information submitted from Dr. Patterson’s office on the 29th. I met Dr. Patterson on April 5th. I had an appointment for blood work and to get a letter of medical necessity with my doctor on April 12th. I had a sleep study May 16th.

Dr. Patterson’s office submitted for pre-approval to Cigna the afternoon of the 29th of May. The next morning, I was telephoned from the surgeon’s office that they were told from Rich at Providence Health Plan Medical Management that I was APPROVED, but I had to extend the referral, because the surgery date wasn’t going to fall within the referral date parameters. I telephoned my PCP's office referral line to get this handled. The following day, I got the new referral number 296708 and informed the surgeon's office. I was then told that (the surgeon's office) had to call in to get details worked out. Later, they called me back and told me that the gal at the insurance said that she would forward the information onto the nurse reviewer and then it would need to go to the medical director.

This is where I paused… and some confusion set in.

If it still had steps to go, I assume that I was told that I was approved prematurely. I was not too worried about it, because I knew that based on the criteria that the insurance gave me, I am more than adequately qualified... The emotional roller coaster of emotions was very difficult and I began to take anxiety medication, Buspar, which the receipt I faxed yesterday shows it currently costs $126 a month. If I take this every month for the next ten years, it will cost over $14,000. I’m also taking prescription sleeping pills to help assist with my insomnia.

I was out of town the 31st of May to June 4th. The week of June 4th the whole Bariatric surgery staff was out until the 11th for a conference. We hoped that during this point something would be resolved. I didn’t receive anything in writing at that point, so on the 13th, I telephoned Cigna and Debbie Ruby told me that 297589 was the approval code for the procedure 43847. Debbie confirmed with her supervisor Velma Roseman who apparently confirmed with Rich at Providence, Velma spoke with Amber at the surgeon’s office and we scheduled a date of July 23rd.

You can imagine how very upset to have received the letter dated June 15th telling me that my requested for surgery was NOT approved. You should have copies of the first and second denial letters. On the 8th of August, a gentleman named Primo who I believe is from your office had me fax copies.

I faxed an appeal letter on the 20th. In the letter I talked about my co-morbid conditions and diet history. I sent information from 24 Hour fitness showing my training sessions and my chart notes from the doctor’s office for every visit over the last five years showing my weight and that my BMI has been 38 to 45 the whole time.

When I received the second denial, I decided to go through the criteria with a fine tooth comb. I know that beyond this 2nd appeal is Independent Review, legal assistance, alternate insurance coverage, self-pay or self-pay out of country. This experience is causing a great amount of strain in my household, and I am hoping that you’ll hear what I am sharing today and overturn the denial.

I made an appointment with my PCP for July 16th. I would have made it sooner, but Dr. Trochmann was on vacation.

At this appointment, we discussed each of the problems that I have that are made worse or caused by my being morbidly obese. In her dictation, (a copy of which is in the August 2nd appeal) she listed mild hypertension, urinary stress incontinence, hemorrhoids, depression, reactive airway disease, patella femoral syndrome in both knees, back pain, anxiety. At this time, we hadn’t diagnosed the diabetes, though at my previous appointment fasting blood sugar was at 125 and noted as borderline.

We started me on Xenical. This costs $150 a month. I made an appointment to start seeing a dietician, which I have been doing on a weekly basis for a few weeks now. Between the first and second appointment I lost one pound. We have developed a 1500-calorie program with adding little by little some low impact exercise during the workday. This low calorie program, combined with the weekly dietician appointments, exercise and Xenical is an ADDITIONAL attempt at a supervised diet. An additional co-morbid condition came to light on the 16th. My fasting blood sugar was 178… the ideal range is 80 to 120. Two hours after eating the ideal range is around 140 and I was at 372. MORE THAN DOUBLE. This was after eating a cheeseburger with half of a bun and fresh fruit. I was referred to take some diabetes classes… the last of which was last night. I’m on Glucophage, which is making a slight difference, but my two week average is still just under 200.

I sent in my second appeal letter by fax and mail on the 2nd of August. Nichole called me about this teleconference on the 14th.

2. CRITERIA

BMI
As mentioned earlier, my BMI has been 38 to 45 over the last five years. The criteria that I received said BMI over 40 for five years or 35 to 40 with co-morbid conditions.

CO-MORBID conditions
·Diabetes
My blood glucose numbers are still higher than the ideal range with medication, diet and exercise. There is the expense of medications, classes, and equipment. The chart on page 2 of the appeal letter sent August 2nd, shows that 92% of diabetics who have gastric bypass surgery are no longer diabetic shortly afterward.

·Reactive airway disease
I use an albuteral inhaler now a couple times daily. When I attempt any cardio-vascular exercise, I get tightness in my chest and have difficulty breathing. I clearly need to be careful when I exercise, so I have seen a trainer at 24-Hour fitness, which is very expensive for me. Page 4 of the fax of yesterday shows a receipt for one session at $64.00. Of course I have gone more than one time, as noted on the information received in the August 2nd appeal.

·My hypertension is mild and fluctuates.

·Gastric reflux is mild.

·Knees
The problem in my knees makes it very difficult to exercise, walk, take stairs. Dr. Trochmann referred me for some physical therapy after diagnosing with patella femoral syndrome. At the physical therapy, I was taught some exercises to attempt to correct the problem, but they have not worked. Because of the pain involved, it is almost impossible to even try to do the exercises. Occasionally when it gets unbearable, I’ll take some acetaminophen, but that only provides minor temporary relief. One of the last pages in the August 2nd appeal is an information page on Patella Femoral Syndrome.

·Swelling in legs and feet.
Every morning I wake up with swollen calves and feet… it hurts to walk. During the workday, I drink 2 to 3 30 ounce cups of water and I take a diuretic. I am drinking lots of water (combined with diabetes), I have to walk to the bathroom a lot, which of course is exercise, but not comfortable.

·I suffer from lower back pain.
The imbalance of my large breasts and excess abdominal tissue make it difficult to maintain a good posture. The last time I was professionally measured, I was a double J CUP, J like jack.… I have seen the chiropractor for my recurring back problems. The acetaminophen that I take for the patella femoral syndrome aids in easing the back pain but only temporarily. The chiropractor has taught me some exercises that would strengthen my back muscles, but they seem to do more damage than good.

·I also have the problem with stress urinary incontinence.
This is the most difficult to discuss, but it certainly is a problem. This is expensive for me for the costs of feminine protection and stained clothing.

·I also suffer from severe depression.
I have been on Wellbutrin since November of 1998. This currently costs $112 a month. I also see a counselor every other week. My co-pay is $10, but I know that it costs around $50 a session for insurance. That is at least $100 a month. I’ve been seeing the counselor regularly since October of 1998.

The long term health costs of my being morbidly obese are far greater than the cost of this surgery as well as any potential surgeries that I may end up needing due to my co-morbid conditions or other health risks.

DIET
There is a chart on page ten of the letter of appeal date August 2nd.

Diet History of Lee Anne Krause

What?	Supervised	How long ?	Weight loss	Weight regain
Chromium Picolinate	Yes	5 weeks	8 pounds	11 pounds
Low Calorie Diet	Yes	13 weeks	26 pounds	30 pounds
24 Hour Fitness 24/5	Yes	Since 10/99	15 pounds	30 pounds
Walk 1 to 5 miles daily	No	10 weeks	40 pounds	60 pounds
Jenny Craig	Yes	20 weeks	20 pounds	28 pounds
Richard Simmons	No	13 weeks	10 pounds	18 pounds
Prism	Yes	39 weeks	37 pounds	82 pounds
Susan Powter	No	9 weeks	5 pounds	7 pounds
Herbal Patches	No	5 weeks	10 pounds	15 pounds
Elliptical Machine (30 min/3x wk)	Yes	13 weeks	30 pounds	40 pounds
Dexatrim	No	9 weeks	15 pounds	20 pounds
Metabolife	No	5 weeks	12 pounds	15 pounds
Cambridge Diet	No	9 weeks	15 pounds	20 pounds
High Protein	Yes	5 weeks	10 pounds	11 pounds

There were regular weigh in’s for 24-Hour fitness, Prism, Jenny Craig and currently at the weekly dietician appointments. In addition to these listed, I have tried half a dozen of the miracle pills that are always advertised in the coupon section of the Sunday paper.

FAMILY HISTORY
My entire dad’s side of the family is or was diabetic. My dad is taking a high amount of medication and shots once in a while and his sister is on shots. His mother, father, late sister and late brother were both on shots. His mother and both sisters were or are obese as is he. His mother had high blood pressure and asthma. Both grandpa and grandpa died from complications of diabetes. My aunt died from a heart attack. My mother is morbidly obese and has high blood pressure that she takes medication for. Her mother and two of her sisters are obese.

My being morbidly obese is having an effect on my ability to live my life to the fullest.

To conclude, I believe that this denial should be overturned. I have explained the processes that I have gone through and then gone over the criteria for this surgery and how I meet it.

I have spent a great deal of time in my research of the gastric bypass procedure. Three of my last college term papers were on the subject. I am a part of several online support groups, as well as the monthly surgery support group that my surgeon’s office oversees. I moderate on obesityhelp.com. It was with the referral and support of my Primary Care Physician, Dr. Rebekah Trochmann, that led me to the surgeon, Dr. Patterson who with her years of expertise has recommended my treatment of the gastric bypass procedure … Therefore, based upon my morbid obese condition, my previously mentioned medical comorbid conditions, my prior weight reduction attempts, my PCP referral, evaluations from a psychologist, dietician and surgeon, I request that you reverse your denial and approve any and all previous requests for gastric bypass surgery that has been recommended as the appropriate treatment for my being morbidly obese.

Sincerely,
Lee Anne Krause

The grievance committee had five business days to contact me via mail of their decision, but they telephoned me not more than five minutes later to inform me that they had overturned the denial. I asked, is that good? The gal said, YES, you get to have the gastric bypass surgery…. WOO HOO.

October 22nd is my day. In the mean time, I am stressing over house/land hunting and offers. YIKES. Lots of changes in my life.

12/04/2001:
I'm just over six weeks post-op. I don't have a scale to know how far down I am in weight. I saw my surgeon on the 21st of November and was down 28 pounds.

My pre-op appointment was Thursday 10/18 and my surgeon sprung a change on me. She was no longer going to be performing the BPD/DS... she is returning to the Scopinaro version of the surgery. At the time, when she explained everything to me, it made sense, but when I got home and posted BOY did the $h!t hit the fan. People froke out. I did some more research. I had to go back into the office the following day and we talked some more. When I left, she assumed that I was kosher with the change, though I was uncomfortable with it. My mother-in-law from California surprised us and showed to stay with the kids during the week. YEA. I did some more research and Monday morning 10/22 when I showed up for surgery, I told her NO. That I wanted the BPD/DS with the stomach removed from the outer portion rather than the lower. She wasn't too happy, but OH WELL. It was something that I would have to live with for the rest of my life.

Fast forward... surgery over. I loved the morphine. Recovery was okay. Liquid Lortab instead of crushed Percoset. I left the hospital Wednesday night. My husband was out of town. So my mother picked me up. When we stopped at the pharmacy on the way home, I didn't feel well, and I vomited in the garbage can in the entrance of the grocery store. I had an accident when I thought that I was going to fart. I ended up going into the bathroom and throwing away my underwear. My mother had to wipe my butt. YIPPEE. I stayed at my parents house, because it was one level. I was afraid to use the stairs and sleep in my waterbed. While I was staying at my parents house, their cat snuck into my room, and it jumped on my bed, and it scared the crap out of me. My dad had to wash my sheets, while I took a shower to clean up. My mom was at work. Good thing that they had a long handled soap brush. My mother-in-law was at my house taking care of the boys and my husband got home on that Friday, so it was okay.

The first few times I took my pain medication, I vomited because I immediately laid down. I didn't give it time to settle. I figured it out after a few times... and I would sit up for a few minutes. I have already made the transition to normal foods. My only mistake was trying nachos too soon. At about almost two weeks post op, I was shopping at Kmart and ate some of the nachos from the deli. I'm so glad that I had to use the restroom, because that is when the nachos came back up. I am so glad that I didn't puke in public.

Anyway... I returned to work at two weeks post-op. I worked slightly shorter days and napped a bit more often than normal, but other than that I've done fine. My weight loss is not as quick and drastic as others because (of course) with the DS, we are able to eat more. I'm not exercising as much as I could. I am very happy about this surgery! My job has become permanent... we are trying finalize our house. Enjoying life with a surgery where people can't tell that I did anything.

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