Throughout my entire life, I have tried many diets from stupid to sensible. I have maintained or lost some weight on each of them, if only a very little, just to regain it all back and then more when I stopped dieting.

I felt the best, most "in control" and the healthiest when I followed the Richard Simmons Diets. I think I did the best on these because I made it more into a game and had fun with it. Along with following the nutritional portion of the diet I was also doing), some kind of exercise everyday. I danced (either classes or in theatrical productions, I swam whenever possible, and I walked (overtime I would try to increase my distance). As I gained weight over the years I have found my weight causes more and more problems with my mobility. It hurts to move and exercise now. I have also acquired more and more health problems over the years.

I truly feel that weight loss surgery is the only hope I have to ever have a "normal" life. It is the tool that I need to help me in my weight loss journey. I know that it is not a miracle but I am determined to make it work. I have already started making adjustments to my habits to help with the adjustments after surgery. I have increased my protein intake, started taking multi-vitamins, I only drink water now and I have started talking walks again. I hope to increase the distance I walk as I lose weight and feel better.

My Letter to the Insurance Company

October 8, 2002

Blue Cross and Blue Shield of Rochester

Provider Inquiry; Pre-Authorization Request

Rochester, NY 14647

Re: Jennifer A. Chase

Request for Pre-Approval for Gastric Bypass

Note: (I meet both Milliman and Robertson and U.S. Federal Guidelines)

1. U.S. Federal Clinical Practice Guidelines for the Treatment of Obesity set down in the National Institutes of Health Consensus Conference. Released June 17, 1998, the Federal guidelines on obesity were by the National heart, Lung and Blood Institute (NHLBI), in cooperation with the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK).

Dear Sir or madam:

I am writing to request your pre-approval for gastric bypass surgery.

I am five foot eight inches tall and I weight ____ pounds. My body mass index is____. The body mass index is calculated by dividing a persons weight in kilograms by their height in meters squared. When a mans BMI is over 27.8, or a womans exceeds 27.3, that person is considered be obese. The degree of obesity associated with a particular BMI ranges from mild obesity at a BMI near 27, moderate obesity at a BMI between 27-30, severe obesity at 30-35, to morbidly or severely obese for patients who have a BMI of 40 or greater (1,2,3). Since my BMI is ___, I am classified in the morbidly obese category. The annual number of deaths in America attributable to obesity has been estimated to be 300,000 per year (4,5). With my abnormally high BMI I am at a 190% increased risk of death at my present weight.

I ask for your pre-approval for this surgery, and not just because of my morbid obesity, but because of the medical necessities that have arisen. The option of surgical treatment should be offered to patients who are severely obese, well informed, motivated, and who have full knowledge of all of the operative risks. The patient should be able to participate in treatment and long term follow-up. A decision to elect surgical treatment requires an assessment of the risks and benefits in each case. Increased abdominal fat or "central obesity (apple shaped as opposed to pear shape) is an important risk factor associated with the major complications of obesity.

Patients whose BMI exceeds 40 (mine is 74.4) are potential candidates for surgery if they strongly desire substantial weight loss (100 pounds or more), because obesity severely impairs their quality of their lives. They must clearly and realistically understand how their lives may change after operation.

Weight loss surgery has been reported to improve or prevent several co-morbidities such as glucose intolerance and frank diabetes mellitus, sleep apnea, and obesity associated hyperventilation, hypertension, serum lipid abnormalities, and thyroid disorders. A recent study showed that Type II diabetes treated medically had a mortality rate three times that of a comparable group who underwent the gastric bypass surgery. Also preliminary data indicates improved heart function with decreased ventricular wall thickness and decreased chamber size with sustained weight loss. Other benefits observed in some patients after surgical treatment include improved mobility and stamina. Many patients note a better mood, self-esteem, interpersonal effectiveness and an enhanced quality of life. They have lessened self-consciousness. They are able to explore social and vocational activities formally inaccessible to them. Self body image disparagement decreases. Marital satisfaction increases but only if a measure of satisfaction existed before surgery. If marital discord existed preoperatively, the improved self-image may lead to divorce post operatively.

Although obesity is a chronic disease with adverse health consequences, in our society it carries such a stigma that many people including health professionalsdont believe that the obese person deserves any sympathy at all, let alone medical treatment for the condition. Obesity is a physical disability that is intensely stigmatized in our society. Studies have shown a striking inverse relationship between obesity and socioeconomic status, especially among women. Being overweight has a particularly deleterious effect on socioeconomic attainment.

Now, I will detail the issues of medical necessity. I am having significant adverse symptoms from my obesity. I have difficulty standing (for more than a few minutes) , and in doing any kind of exercise, even walking (short distances). I have difficulties performing daily activities such as tying my shoes, bending over to clean or put stuff away, climbing anything, etc. I also am not able to participate in many recreational activities because of my weight. The stress on my body is just too much. Right now, I have nothing close to resembling a "normal" life. Weight loss after having the gastric bypass can allow me freedom to exercise, to heal and to have a real life again.

I suffer from Polycystic Ovarian Syndrome (PCOS). PCOS is one of the most common endocrine problems in women. According to the initial description by Stein and Levinthal in 1935, the diagnosis of PCOS was based on clinical symptoms (oligo/amneorrhea, infertility, hirsutism, and obesity) in the presence of polycystic ovaries. PCOS does account for 75% of women with an ovulatory infertility, 30%to 49% of secondary amenorrhea and 85% to 90% of women with oligomenorrhea. The majority of patients with PCOS are hirsute ( I fall into this category). Obesity is also a frequent finding among women with PCOS. 30-60% of PCOS patients are overweight. Obese women have more menstrual abnormalities, endocrine abnormalities and higher rates of uterine and ovarian cancer than normal weight women do. Since my mother and grandmother have both had total hysterectomies, I realize that with my obesity and family history I am at a great risk of developing uterine cancer in the future. If I am allowed to have gastric bypass surgery, the weight loss will not only reduce the likelihood of cancer but will also allow me the chance of having a child in the future. All of my medical professionals have counseled me and told me that at 489 pounds I have little to no chance of even conceiving. PCOS doesnt entirely go away, regardless of surgery or medication, but the ability to have a child will be 90% more likely with weight reduction and will save money in the long run on fertility treatments.

Arthritis is a major co-morbid condition that I do not have yet, but if I stay at this weight I will develop in the next few years. One of my most intolerable problems is the almost constant pain of my weight bearing joints. An increase in body weight adds trauma to weight bearing joints and excess body weight is a major predictor of osteo arthritis (of which my grandmother and mother suffer from).This is a mechanical problem and not a metabolic one. The hips, knees, ankles and feet have to bear most of the weight of the body. 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(my grandmother has had hip replacements). Unfortunately, the obese person faces a disadvantage there too joint replacement has much poorer results in obese. Many orthopedic surgeons refuse to operate on severely overweight patients. The permanent weight loss of gastric bypass surgery will markedly decrease problems with arthritis and the ever-increasing expenses to the insurance companies that will surely follow.

Because of my weight, I am depressed. I am on Prozac to help control my depression. My depression stems for being over weight. Seriously overweight people face constant challenges to their emotions: repeated failure with dieting, disapproval from family and friends, sneers and remarks from total strangers and even the medical community at different times. We often experience discrimination at places of employment (or potential places of employment), and can not enjoy theatre seats, or ride in a bus, train, or airliner with out special, costly accommodations. There is no wonder that anxiety and depression might accompany years of suffering from the side effects of a genetic condition one which some skinny people believe should be easily controlled by will power. I am at my greatest weight ever. I am depressed and anxious because of my limitations and am aware of my worsening co-morbidities and significant risk of further serious health problems if I am not able to permanently lose weight. Just the experience of attempting to get this surgery approved has caused me great emotional stress that I know is not good for me but I want to be healthy. I NEED to be healthy! After years of being morbidly obese, I have come to realize, I do not make a good fat person. I have too much ambition and energy to be this way. I am an active person. I like to perform (singing, and playing my clarinet) but I have not had many opportunities because of my size. I love to play softball, baseball, and volleyball, but because I am restricted on running, I am unable to do this. I get winded very easily walking up stairs. I love to swim and bike, but I am unable to do any of this for more than a few minutes before I am exhausted. I know that I have been discriminated against when I have been on various interviews for jobs with in the business end of the entertainment industry. I would like to lose weight to be able to grasp my dream of becoming a music business professional. At this weight most people in the industry who look at me, think that I could not keep up with the pace of the work.. I have been very strong for the most part but after so many times of this same kind of rejection it grates on a person.

As I have said above I do become short of breath easily. Actually I become short of breath at any exertion. I have already stated that climbing a flight of stairs winds me. I also have a difficult time performing the ordinary day-to-day duties of living, such as shopping, cleaning, getting in and out of cars or chairs, boarding a bus, and bending over for any reason. There is a history of morbid obesity in my family and genetics has dealt me the FAT card. I have never been able to enjoy life to the fullest. I have always had restrictions because of my weight. I am very excited to know that with the help of this surgery I could lose some of my limitations and live life to the fullest. Obese people 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. This condition 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. Losing weight would cure and respiratory problems to this effect.

I have chronic skin problems. I have acne all over my body. I am in a constant battle with yeast infections, skin tags, and chronic rashes in the folds of my body. Sometimes they are so bad the skin burns and feels raw. The obesity causes these skin folds so that skin rubs on skin and the moisture trapped in those creases cause the infections, boils, and rashes. The excess sweating that I suffer from doesnt help these conditions and actually contributes to making them worse. Another very difficult problem to address is physical hygiene. I consider myself to be a very clean person, or at least I try. The sweat that gathers in the folds of my fat begins to smell bad only after a couple hours into the workday. Using deodorant in between the folds helps some, but then there is the problem of cleaning it out properly. Sometimes parts of my body are hard to reach. The weight loss from the surgery would decrease the skin folds and make good hygiene easier. It would allow myself to keep myself clean, as clean as I would like to be, every day, all day.

In retrospect, you need to be aware that I have made many attempts to lose weight some of the more traditional ways. Attached to this letter is a diet history. I have included some type of exercise with each of my attempts. I can lose a little bit of weight, but then regain it all plus a little more. There is not one study that shows that dieting brings permanent weight loss. The National Institute of Health , in 1991 and 1992 consensus statements, rebutted conventional diets for morbid obesity and pointed to this important fact: Diets alone can not be successful for the morbidly obese. The article "The Man Who Could Not Stop Eating" in the July 9, 2001 edition of The New Yorker states that "given the complexity of appetite and our imperfect understanding of it, we shouldnt be surprised that one treatment has been found to be effective, and oddly enough, it turns out to be an operation [bariatric surgery]" (7). Gawande continues to tell us that morbidly obese people who have had this surgery realize that "the changes werent just physical[It gives them a ] profound and unfamiliar sense of will power" (7). This surgery is a tool to be used by the morbidly obese to regain control of their lives, to become happy, healthy, productive citizens instead of medical drains on our community and economy. I realize that is surgery is just a tool and I will use this tool to the fullest extent if given the chance to use it. I am filled with determination for this to work.

Obesity has shown to directly increase health care costs. In an article in the March 9, 1998 issue of the Archives of Internal Medicine 17,118 members of the Kaiser Permenente Medical Care Program were studied to determine the association between body fatness and health care costs. The results show those patients with BMIs greater than 30 had a 2.4 times greater risk for increased inpatient and outpatient costs than patients did with BMIs under 30. For patients with BMIs greater than 30 the study also showed increases in health care costs related to diabetes and hypertension.

Americans spend and additional $33 billion dollars annually on weight reduction products and services including diet foods, products, and programs. Most of these expenditures, as evidenced in my case are not effective. Rather it can be expected that I will continue to gain over the ensuing years and add to this present list of obesity associated illnesses.

Surgical treatment is medically necessary because it is the only proven method of achieving long term weight control for the severely obese. Surgical treatment is not a cosmetic procedure. Surgical treatment of severe obesity does not involve the removal of adipose tissue (fat) by suction or excision. Bariatric surgery involves reducing the size of the gastric reservoir, with or with out a degree of associated malabsorption. Eating behavior improves dramatically. This reduces caloric intake and ensures that the patient practices behavior modification by eating small amounts slowly, and chews each mouthful well. Success of surgical treatment must begin with realistic goals and progress through the best possible use of well-designed and tested operations. These have been worked on over the past 30 years and are now standardized, clearly defined procedures, will well-recognized and documented outcome results.

I do not want this surgery just so I can look good. I NEED it for health reasons, as you can and will clearly see. I have many co-morbidities due to my obesity which include but are not limited to:

1. Family history of hypertension
2. Family history of diabetes
3. Family history of stroke
4. Family history of heart disease
5. Hypothyroidism
6. Excess testosterone
7. Excess facial and body hair (Hirsutism)
8. Acne
9. Rashes
10. Chronic skin infections
11. Excess sweating
12. Frequent yeast infections
13. Hormonal abnormalities
14. Possible infertility
15. Polycystic ovaries
16. Lower back pain (cant stand/work for more than five minutes without lower back pain)
17. Ankle/knees swelling
18. Shortness of breath upon exertion
19. Decreased exercise tolerance
20. Depression/anxiety
21. Fatigue
22. Activity intolerance; shortness of breath and severe fatigue even with minimal activity
23. Decreased endurance limiting daily activities, including but not limited to walking, housework, working, dressing, standing, getting up, bathing, sitting, and traveling.
24. Irregular or absent periods
25. Skin tags
26. Insulin resistance
27. Obstetric and gynecological complications
28. Broken/fractured bones in feet
29. Rough callous on the bottoms of my feet
30. Partial loss of mobility

It has been documented that most of these problems can be helped, if not cured by losing weight. I will not take up any more of your valuable time by educating you on each and every co-morbidity that I possess. I have done a tremendous amount of research on the gastric bypass surgery. I have learned much about this surgery and what it will do for my life. This is why I want and need the surgery. Prevention of secondary complications of severe obesity is an important goal of management. Therefore, the option of surgical treatment is a rational one supported by the time-honored principle that diseases that call for therapeutic intervention that are less harmful than the disease being treated. After reviewing my family medical history, I believe that you will agree that to not have this surgery will surely lead me to having more severe medical problems in the future.

My family history is as follows:

Significant Medical Family History for Jennifer A. Chase

Mother, age 49

Father, age 52

Obesity, Type II Diabetes, High Cholesterol

Brother, age 20

Morbid Obesity, hypertension

Maternal Aunt, age 52

Fraternal Aunt, age 50

Type II Diabetes

Maternal Cousin, age 34

Obese, Type II diabetes

Maternal Grandmother, age 78

My genetics and morbid obesity put me at an increased risk of heart disease, hypertension, diabetes, and cancer, specifically uterine cancer. Morbid obesity runs rampant throughout my mothers side of the family, and I look exactly like my mother. We carry our weight in the same spots.

Without this surgery, I am looking at the possibility of multiple surgeries in the future. I have been told by my Primary Care Physician, Dr. Jill Potts of Canandaigua Medical Group, that this one surgery could improve and/or eliminate most if not all of my co-morbidities plus eliminate the need for other surgeries and medications. It seems much more cost-effective to have this one surgery instead of others and more medications.

The "Patient Selection" section of the National Institute of Health Consensus Statement of 1991 states "a gastric restrictive or bypass procedure should be considered only for the well informed and motivated patients with acceptable operative risks." Therefore, I am writing this letter to ask for pre-approval for this surgery. I am also writing this letter to confirm my understanding of the risks and benefits of weight loss surgery and my motivation to commit to long term medical follow-up and drastic lifestyle changes required to ensure my own success. My understanding of the surgical procedure is as follows: the procedure creates a small food "pouch" at the upper end of my stomach with a capacity of less than two ounces. The pouch is connected to the middle of my small intestine(jejunum) by a small outlet of about 1.0-cm in diameter, thus bypassing the remaining portion of the stomach and some of the small intestine, the duodenum and the first part of the jejunum. The bypass surgery functions by limiting the amount of food or liquid that can be eaten or drank at one time. It also limits the amount of calories and nutrients that can be absorbed, due to the partial intestinal bypass (malabsorption).

Even with full knowledge and understanding of the potential risks and complications of gastric bypass surgery, I know that for me, the health benefits and improved quality of life (of significant weight loss) will far surpass the potential health risks and complications. Further, I know that the same medical problems that increase my risk of any major surgical procedure, including bariatric surgery, also strengthen my need for permanent weight loss.

I am fully aware that bariatric surgery is not a magic cure for my obesity. I know that the surgical procedure alone will not achieve my desired weight loss; it will only create a tool that I will have to work with on a daily basis to lose weight and maintain an optimal level of health after surgery through the maintenance of the lost weight. I am aware that my maintenance will include exercise, changes in the types of food I eat, liquids I drink, the number of meals I will eat per day, how thoroughly I chew, and how fast I eat. I realize that I will need to take specific vitamin and mineral supplements for the rest of my life. I also realize that behavior modification will be critical in attaining acceptable long-term weight loss and that the attendance of group support meetings will be crucial to my success especially in the first year. I also know that behavior modification is an important educational process that will be made easier as a result of surgery. In preparation for the surgery I have started practicing some of the behaviors I listed above.

I am willing and committed to following the required after care program after surgery because my primary goal is to achieve improved health. I know that undergoing bariatric surgery will enable me to achieve that goal.

Finally, I do understand the condition for which I seek treatment, morbid obesity, is a chronic condition that is difficult to treat. Persons, such as me, with a Body Mass Index (BMI) above 40 are as suffering from morbid obesity. I understand that the decision to undergo bariatric surgery is complex and intensely personal. I know that the decision to undergo bariatric surgery is a decision that will change the rest of my life in a dramatic and irrevocable way.

I ask you to pre-approve this surgery so that I can become a healthy, productive person. I want this surgery. It will save my life and give me life! It is known that this surgery gives one a better mood, self-esteem, interpersonal effectiveness, and an enhanced quality of life. As one loses weight they find "hope." So, I beg you, please approve this surgery and give my life a little bit of hope.

I believe that I am an excellent candidate for Gastric Bypass Roux-en-Y Surgery. I believe that many of my current health problems would be ameliorated by significant weight loss, and that future health consequences of my increasing weight would be prevented. Your approval of this surgery will save my life and you will give me a quality of life that I have never truly known. Thank you very much for your consideration.

Sincerely,

Jennifer A. Chase

Reference Sources:

1. Weighing the Options: Criteria for Evaluating Weight-Management Programs. Institute of Medicine, National Academy of Sciences. 1995; 50-51.
2. Kuczmarski, R.J., Johnson, C.L., Flegal, K.M., Campbell, S.M. Increasing prevalence of overweight among U.S. adults. Journal of the American Medical Association. 1994;272:205-211.

    

3. Troiano, R.P., Kuczmarski, R.J., Johnson, C.L., Flegal, K.M., Campbell, S.M. Overweight prevalence and trends for children and adolescents: The National Health and Nutrition Examination Surveys, 1963 to 1991. Archives of Pediatrics and Adolescent Medicine, 1995; 149: 1085-1091.
4. Daily Dietary fat and total food energy intakes: Third National Health and Nutrition Examination Survey, Phase I, 1988-1991. MMWR Morbidity and Mortality Weekly Report. 1994;43:116-117, 123-125

    

5. Weight Control: What Works and Why. Medical Essay. Mayo Foundation for Medical Education and Research, 1994.
6. The Neuropathy Association. http://64.29.97.20/index.asp, 2000.

    

7. Gawande, Atul. "The Man Who Couldnt Stop Eating." The New Yorker. 9 July 2001. 66-75

My PCP's Letter

Coming Soon