The Appeal

To whom it may concern:

I am writing to appeal your decision to deny authorization for laparoscopic adjustable gastric band surgery, a decision which was made in February 2008. It is acknowledged that weight-loss surgeries are currently excluded under my insurance plan. However, this surgery is medically necessary to treat my case of Obstructive Sleep Apnea (OSA). I implore you to reconsider coverage for the reasons below.

I have been fighting OSA for nearly my entire adult life. Over the last 12 years I’ve endured excessive daytime sleepiness, fallen into deep depression, nearly died one night when I stopped breathing for an extended period of time during sleep, missed countless hours of work, and suffered through relentless side effects. These include depression, memory loss, mental dullness, sleep paralysis, general fatigue, restlessness, dizziness, numbness in my upper body, morning headaches, mood swings, panic attacks and general lack of motivation.

My sleep apnea has been maddeningly resistant to a myriad of treatments. I’ve had 12 overnight sleep studies since 1996. Each time, doctors have prescribed treatment, which I have followed carefully, but in the end have been ineffective. I have undergone four surgeries in attempt to open my airways:

• Tonsillectomy/Adenoidectomy in 1996
• Uvulapalatopharyngoplasty (UPPP) in 1997
• (Repeat) Adenoidectomy in 2003
• Sinus surgery in 2007 (cauterization of turbinates, removal of scar tissue and clearing of sinuses)

In addition, I’ve tried four different CPAP and BiPAP devices; tried 15 different CPAP masks; tried countless combinations of CPAP air pressures, both heated and non-heated humidifiers; chin straps; embarked on exercise and eating regimens; gone through repeated CPAP mask desensitizations; tried three different adjustable mandibular advancement devices; tried two different tongue restraint devices; and taken two years of allergy shots in attempt to improve my breathing. With my current BiPAP device, I’m using the maximum air pressure available (25 cm H2O, which is extremely high) and still have not had relief. I’ve taken various prescriptions in attempt to mitigate the effects of sleep apnea and improve my breathing. (Currently I am taking Provigil, Paxil, Nasonex and Claritin daily; and Albuterol as needed.)

I have family history of stroke. As you know, OSA dramatically increases the chances of having a heart attack or stroke. On several occasions this year, I have felt as if blood was not circulating properly to my head. On one occasion I nearly passed-out. On another occasion, I fell asleep on my keyboard at work. In 2007 I had five episodes of sleep paralysis, during which I was alert to my surroundings, but unable to move my body.

In the space of just 6 years I gained 100 pounds. I’ve made repeated attempts to lose weight, including two periods supervised by medical professionals. Each time, I lost some weight, but it rebounded within months, and I gained more.

Over the same period of time I have missed approximately 500 hours of work, and spent approximately $30,000 on various treatments, devices, medications and copays. (Similarly, my medical insurers have already paid-out over $150,000 in sleep apnea-related medical bills for me; a large portion of those were paid by your company.) It’s become agonizingly clear to me that devices, prescriptions and diets are wholly insufficient to treat my severe OSA.

Obstructive Sleep Apnea is defined as five or more episodes of apnea or hypopnea per hour of sleep in individuals who have excessive daytime sleepiness. According to my most recent sleep study a few months ago, I have 120 apnea/hypopnea episodes per hour; quite literally I can’t even sleep for 30 seconds without stopping breathing. (After my last surgery, the doctor insisted I stay in the hospital overnight because my apnea was so bad.) I am over 100 pounds overweight, I have a BMI of 45, and I score 14 on the Epworth Sleepiness Scale, which is considered dangerous. As you can imagine, I’m at extremely high risk for some very big health problems.

As my condition has grown worse, I have had several episodes where I wake-up choking. My significant-other has witnessed events where I stop breathing for long periods of time. When I lay down to go to sleep, I sometimes really do wonder if it will be for the last time.

My doctors have advised me that I should have weight loss surgery, since we’ve exhausted all other possible treatments (other than tracheotomy). These doctors include Dr. xxxxx, MD (my family doctor), Dr. xxxxx, MD (ENT specialist and surgeon), Dr. xxxxx, MD (sleep specialist), Dr. xxxxx, DMD (sleep dentist) and Dr. xxxxx, MD (gastric surgeon), and they consider the surgery medically necessary to treat my condition. Over the long term, weight loss surgery has a significantly higher success rate than eating/exercise regimens alone. By losing the weight, the layers of fat in my throat will shrink, thereby clearing my airways. This is my only hope of escaping the stranglehold that OSA has had on my life.

I fully understand that under my policy, gastric surgeries are normally not covered as treatment… at least, not for morbid obesity. However I would respectfully ask you to please consider it as treatment for severe and otherwise un-treatable Obstructive Sleep Apnea. We’ve exhausted all other options, and I’m barely able to function. Without the surgery, I fear I will be stuck in an endless cycle of failed attempts to lose weight, risking stroke, losing more work, taking endless prescriptions and aimlessly trying variations on treatments that just don’t work for me.

I am certain that by covering the cost of the Lap Band procedure, your company would save a lot more money down the road. If left untreated, my condition may require even more complex and costly treatment in the future.

I have included a few documents with this letter, notably a letter from my first diagnosis in 1996, as well as the current surgery authorization request from Dr. xxxxx. I am happy to furnish any additional documentation that you may require, including medical records, doctor letters, sleep studies, weight histories, receipts, etc. Please let me know if any additional information will be helpful to my request. I can be reached any time at (xxx) xxx-xxxx (cell/home/work).

Thank you for your immediate attention to this matter.

Sincerely,

Michael _____,
Subscriber # __________

A little dramatic? Yes, but it’s all true.

My intention here is not to demonize the insurance company. They actually offer packages that cover the surgery, but last year my employer elected not to spend the additional funds required. In any case, I’m still waiting to hear back if they’ll cover the procedure. But I’m going to have the surgery done, no matter what.

The strange doctor’s office

What a strange stay at the doctor’s office. (It’s my first visit here.)

The waiting room is darkened, and all decked-out for Halloween… Pretty elaborate. A warm glow is emanating from an aquarium.

Mystical Middle-Eastern music is playing over the intercom.

They called me and asked if I could come in at 3:20 (?) instead of 4:00. I’ve now been here an hour, and still waiting.

A very charming, 70-ish Jewish man is chatting with the receptionist. He’s asking a favor while he awaits his appointment… would the young lady mind making a few photocopies from a homeopathic remedy book for him? He wants to share it with some friends. He’s also brought assorted candy for any youngster patients. And a wood-carved armadillo for the receptionist, too… from Argentina. He is apologetic and makes sure the receptionist knows he’s not in any hurry, and if she needs to get back to work, he can wait. He has lots of time, he assures her, smiling… eyes twinkling. For some reason this person just completely intrigues me.

A blue-collared mustachioed Latino bear enters, with wife and two kids in tow, all babbling away in Spanish.

A man pushes a wheelchair in. The 40-ish woman in the chair has streaks of black and gray dyed hair. She seems to be intentionally going for the goth look, and it actually works well for her.

Despite the fact that my phone is on mute, it just emitted an audible camera snapshot sound as I took this picture.

The older man begins to talk to me, smiling. I usually hate making small-talk with strangers in doctors’ offices (among other places), but this man’s charm had already captured me. I began to talk to him. I put away my cell phone… something I just don’t do very often. He pays compliments to the staff and the doctor. He tells me about the procedure he had, and how one of his teeth is very sensitive now. I want to keep talking to him, but now he’s being summoned for his appointment. “It’s a pleasure to meet you!” the guy says, beaming. I smile back and agree that it was nice to meet him too, and actually, it was.

I’ve now been summoned in for a CT scan.

I’ve just completed a questionnaire about symptoms of sleep disorders. “Have you experienced any of the following in the last year?” Why yes. Yes I have. I scored about 50%.

A few minutes pass. My CT scan is now available, and shown on a computer screen before my eyes, in dazzling 3D. I recognize the outline of my face in the side profile. The computer has automatically added a vector line showing my oversized tongue. I’m in the doctor’s personal office, waiting for him to come in so we can chat about my long, up-and-down, stubborn sleeping problems that have so riddled me.

Our chat is long and repetitive. Maybe he’s accustomed-to patients who need things explained to them over-and-over, and in varying intonations before they “get it.” Or maybe this doctor likes to talk. Or maybe he’s killing time. In any case, I had to nod about 50 times before he realized that I “got it” and we could move on.

He begins to dictate a letter to my doctor. In front of me. Into a phone. It takes nearly 10 minutes. I try not to interrupt when he says that I’d had my tonsils out as a child. Actually no, I had them out in 1996. He nails everything else, pretty-much perfectly, and closes the letter.

The doctor asks me… would I like a CD-ROM with all my 3D images? Why yes, yes I would. The receptionist reaches for a blank CD. “That will be $20 dollars, please.” Umm, never mind, I’m watching my spending.

Health

I am doing the following to improve my health (sleep apnea, among other things.)

• Getting ready to do another (home) sleep study. (Some doctors will let you do a simplified home sleep study these days, so you don’t actually have to go into a facility. Yay!) This will tell me how my blood oxygen levels are, and tell me how many apnea/hypopnea episodes I’m having.
• Per doctor’s advice, starting to take supplements of Iron, B12, Omega 3 and Folic Acid.
• Started getting more physical activity. (I’m not making any significant eating changes at the moment. More on that later.)
• Ordered-up a tongue-restraint mouthguard (intended to keep large tongues from blocking airways. Smart-ass remarks welcome.)
• Putting together some measurable health goals (besides weight. More on this later.)
• Having some nasal surgery done (see story below.)

Back in 1997, I had my tonsils and adenoids removed, then had the UPPP surgery (trimming of uvula and soft palate.) This was enough to treat my sleep apnea for several years. But over time, it came back.

In 2003, my doctor advised me that my adenoids had grown back. (“They can do that!?”) So I had them removed… again. Soon, I marveled at how well I could breathe through my nose, finally. That lasted for about six months. Then I was back to my same ol’ chronically congested self. (I’m a mouth-breather because it’s just not possible to breathe through my nose 90% of the time.)

Even after about two years of weekly allergy shots, I was still congested all the time. We also tried every possible decongestant, nasal spray and treatment.

So I had an interesting doctor’s appointment a couple weeks ago. He took a look back there, and figured-out (at least one of the reasons) why I still can’t breathe through my nose… there’s a lot of scar tissue still remaining from that second adenoid surgery. It was supposed to have cleared-out a long time ago… but instead it crusted-up and is now blocking my internal airways.

For that reason, I’ll be going under the knife. While I’m there, the doc will:

• Clear-out the 4-year old scar tissue from my last adenoidectomy.
• Laser-cauterize some of the tissue in my nasal turbinates.
• Clean-up some deviations in my nasal passages. (I don’t have a full-on deviated septum per se, but just some stuff that needs to be smoothed-out.)

I am really excited at the prospect of seeing some relief. I can’t even tell you what an awful state my health is in right now, on many, many fronts.

The doc says ‘no more caffeine.’

Click photo above, or view all photos uploaded by SluggoBear

*UPDATE* I’m not a coffee drinker, but I love my Diet Coke.

“The System,” “The Runaround,” “Bureaucracy.”

“The System,” “The Runaround,” “Bureaucracy.”

Every one of us, at some time or another, has called a supposed “service-oriented” organization for help, only to receive “the runaround.”

For example, you call your bank to report an error on your statement, and they cannot help you because of some policy, or some process, or some form. You submit the requested form and it gets lost. You have to call back and explain the whole story, from the beginning to someone new. Your call gets disconnected. You call back. You tell your story again. You are advised that you called the wrong department, but the representative will be happy to transfer you. You wait on hold again. You finally get to someone in the other department, who advises that, unfortunately, another department needs to handle this, and they are only open from 9am to 4pm, Eastern Standard Time. You get through, and they can’t help you, because you should have submitted the form within 30 days.

I normally don’t share sob stories. We all have them. No one wants to hear whining.

But I think this story just exceeds the bounds of ridiculousness.

I’m not looking for sympathy here. To avoid making this TOO drawn-out, I’ll attempt to summarize the situation as succinctly as possible.

Scenario: Because I am a consultant, I am required to purchase my own medical insurance coverage. In Connecticut, the policy cost me about $150 per month… and in fact, this gave me pretty good coverage.

Call # 1. Because I was moving to California, I was told that my policy (at Blue Cross of Connecticut) would eventually have to be canceled. In the meantime, I could get urgent care when I’m in California, but couldn’t get a regular doctor there. I was specifically told that I should get approval in advance before seeing any doctor in California, otherwise any claims would be denied.

“OK, fine. Could you just change my mailing address for now, please?”

“I’m sorry sir, if we change your mailing address, your policy will be automatically canceled.”

FINE. Leave it. See if I care.

FEBRUARY 2005.

Moved to California. Needed to see a doctor. I called and got the pre-approval. After the appointment, I called insurance company again, just in case, to alert them to the forthcoming claim.

Call # 2. “Sir, you don’t need pre-authorization. Just have the doctor submit the claim. It will go through.”

FINE.

I apply for insurance at Kaiser. Denied, because I’m overweight.

Apply at Blue Shield of California. They have a “convenient” web application, which took me approximately one hour to complete. At the end, the form didn’t work. I called their web support. They advised that just to be safe, I should fill-out the form on paper and mail it. Three weeks later. Declined, because I’m overweight and have sleep apnea.

Apply at Blue Cross of California. Declined. Overweight and blah blah blah.

JUNE 2005.

Investigate other medical plans. After several days of evaluating them, I decide that I should find-out if Blue Cross has any other options.

I receive a letter in the mail, advising that the claim for my doctor visit (in California) was declined. Because I did not get pre-approval.

(GRITS TEETH. THEN LAUGHS AT THE IDIOTS.)

JULY 2005.

I learn about something called a “conversion plan.” If you were with an associated Blue Cross plan (for example, Blue Cross of Connecticut), you can apply for this unique plan in California, and you cannot be declined for any reason… as long as you paid all your premiums. Sweet!

Call # 3. “Yes sir, just apply for the conversion plan. I’ll send you the forms. But you cannot apply for the HMO plan, instead you must apply for the PPO plan.” (PPO is more expensive, about $300 a month. Yikes. But I guess I don’t have any other options.)

FINE.

One month later.

Because Blue Cross of Connecticut was sending my bills to a Connecticut address, the postal mail-forwarding added several weeks delay to me receiving my premium bills. Because I’d been juggling TONS of things throughout the move, I forgot and was late on two payments. I’m assessed the appropriate service charges.

Call # 4. “Hello, I’d like to check on the status of my application?”

“I’m sorry sir, you have the wrong department, let me transfer you.”

“Hello?” “Yes I’d like to check on the status of my application?”

“I’m sorry sir, we have no record of that. Why don’t you try calling an insurance agent? They can help you through the application process.”

Whatever. I send the application again, and wait two weeks.

Call #5. “Sir, you’ll need to contact your old insurance company and have them send us a T6 Certificate. This is proof of start and end date of your previous coverage.”

FINE.

Call # 6. I request that the old company forward a “T6 Certificate, whatever that may be.”

“Sir could you please confirm your current address.”

“Well, do you want my Connecticut address? Or my California address.”

“Sir I’ll need your current address.”

“OK, knock yourself out. But last time they told me you couldn’t change the address, or my policy would be automatically canceled. But my new address is blah, blah, blah.”

After being on the phone for 20 minutes.

“I’m sorry sir, I can’t change your address. It will cancel your policy.”

Great. Thanks. Hate to say, I told you so.

Still they send, supposedly, the coveted T6 Certificate to Blue Cross of California.

Four more weeks.

Blue Cross of California sends me a letter, advising that my application was rejected because I hadn’t submitted a T6 Certificate.

FINE.

I resubmit the application, and,

Call # 7. I ask Blue Cross of CT to fax T6 certificate. Again. They say they already did, but fine, they’ll do it again.

Wait two weeks.

Call # 8. “I’m checking on the status of blah, blah, blah.”

“I’m sorry sir, we still have not received the T6 Certificate.”

FINE.

(In my head: How about you give me your fucking street address so I can hand-deliver it my goddamn self?)

“Why don’t you give me the mailing address so I can make sure a hard-copy gets sent as well?”

“That would be fine.”

Call #9, #10, #11, #12. “They didn’t send it.”

“Yes we did.”

“No they didn’t.”

“Please allow 15 working days, blah, blah, blah.”

“Sir, we sent the certificate via fax and in postal mail.”

FUCK. All I want to do is make a simple appointment with a doctor so I can continue treating my sleep apnea. Is that asking too much?

Call #13. “I’m sorry sir, you selected the wrong option. Next time you call, please select option 4, then option 3.”

“OK. Can you tell me what Option 1 is for? So I’ll know for next time? Is that for Member Services or Application Status?”

“I’m sorry sir, I don’t know. I only know that you should hit option 4, then option 3, and that I can’t help you with your request.”

Yeah. No shit.

TODAY: OCTOBER 5, 2005

Call #14. “Sir, we did receive something from your old insurance company.”

“GREAT! I’m so glad it was processed.”

“But sir, we don’t seem to have an application for you. Could you please send it?”

(GRITTING TEETH AT THIS POINT, then backs-off.)

“Please ma’am. I am absolutely certain that you DO have my application. In fact, YOU guys are the ones who told you needed a T6 Certificate to complete it.”

“Oh, I see. Wait a minute.”

(HOLD MUSIC)

“Sir, I see here that your old company sent a T7 Certificate. But actually we’ll need a T6 Certificate. Please have them send it and allow 15 working da…”

“PLEASE. MA’AM. I know this isn’t your fault personally. But I’m in a fix here. You see, I need to see a doctor to treat my sleep apnea. But I can’t do that until I have medical coverage in California. Do you see my dilemma? Can I just ask a question? I mean… I submitted that application in July. Why did this take so long? You guys are in the Blue Cross network, right? I thought the whole point of this conversion plan was to make it easier for someone to move across the country, and get into another Blue Cross plan?”

“Well yes sir, we try to make it as easy as possible. Hmmm… it appears they did not terminate your policy in Connecticut yet. Isn’t that strange?”

“Well, NO actually, and I’m damn lucky they haven’t terminated it yet, because otherwise I would be un-insured now, wouldn’t I? Apparently they kept the policy going because you guys can’t seem to process my application.”

“Please hold, sir.”

(Ten minutes later.)

“OK sir, I found your application. But I’m sorry. Because you are coming from out of state, you need to fill-out a different application form.”

WHAT?????????!?!?!!?!?!?

(Tries in vain to regain composure and serenity)

“You could’ve told me that when I submitted the form. May I remind you that it was submitted to you in July.”

“But sir, we didn’t know you were coming from out of state.”

“THE HELL you didn’t know!! If you’ll look, it’s right there, on the first page of the application! Anthem Blue Cross of Connecticut!”

(Breathe in, breathe out. Breathe in, breathe out.)

“Sir, I’m sorry about the situation. There’s nothing I can do until you…”

“FINE. FAX ME THAT FORM PLEASE. AND PLEASE DO IT TODAY.”

(Tries to go outside to walk it off.)

So I get the fax. Because I transferred from out of state, want to guess what the monthly premium is?

ONE.

FUCKING.

THOUSAND.

DOLLARS.

PER.

MONTH.

JESUS CHRIST. ARE YOU KIDDING ME? DOES ANYONE ACTUALLY PAY THAT??? IS THERE SOME MISTAKE?

Call # 13. “Ma’am, does anyone actually pay that? Is there some mistake?”

“Yes sir, some people do pay that premium, because there are no other options for them.”

“Thanks. I appreciate that sentiment. Have a nice day.”

(click.)

(Sluggo buries face in his hands.)

I’m going to make an appointment with a doctor and I’m going to just pay him in cash.

(P.S. Don’t worry, I’m still insured in case of an emergency, and I will be fine, and I will find local medical coverage, somehow. But don’t this just beat all!?)