To:   ABC Insurance
Re:    Claim Review Board

Name of Patient/Insured:    Jane Doe
Social Security/Insured ID#: XXX-XX-XXXX
Employer: ABC Company
Group No: 12354

Dear Sir or Madam:

Please let this letter serve as my petition to you to have my laparoscopic Roux-En-Y gastric bypass surgery paid at the in-network benefit level, even though my surgeon is not an in-network provider.

Once I decided I needed this surgery, I began my search for a surgeon by contacting the American Society for Bariatric Surgeons (ASBS). I learned from the ASBS that the only surgeon in my local area who is a member of ASBS is Dr. #####, here in Columbus, Georgia. Dr. #### is an in-network provider with Quality Healthcare Partnership (QHP). However, when I called Dr. ####’s office, I found that the only type of weight loss surgery he does is the "open" Vertical Banded Gastroplasty (VBG).

After and entire year of researching the various weight loss surgery procedures, I have concluded that I do not want to have the VBG procedure for several reasons, most importantly, the high rate of revision surgeries that VBG patients require. Furthermore, VBG patients lose a lower percentage of their excess weight and have a greater chance of gaining the weight back.

The type of surgery which I feel is best for me is the laparoscopic Roux-En-Y (RNY) surgery. I have chosen this surgery because it is considered to be the "gold standard" for bariatric surgery. Studies have shown it to be the safest, most effective surgery for losing weight and maintaining the loss. The Roux-En-Y surgery is performed both open and laparoscopically. My research revealed that the laparoscopic approach is, by far, superior to the open surgery for many reasons. First, and most importantly, the laparoscopic surgery does not require the long, vertical incision that the open requires. All that is required are 5 or 6 small incisions which range from ¼" to ½" in length. Open RNY surgeries usually require 5 to 7 days in the hospital and a 6 week period of recovery at home, whereas the laparoscopic RNY surgery typically only requires a 2 day hospital stay and less than a week of at-home recovery. I see no valid reason to spend seven (7) weeks in recovery and out of work with the open surgery when I can spend just one (1) week out with the laparoscopic surgery. (In addition to unnecessary personal discomfort and inconvenience that a longer hospital stay would require. A longer hospital stay equals higher medical expenses, which, in turn, means greater overall costs.) Furthermore, there is a risk of developing hernias with an open surgery that just simply does not exist with the laparoscopic surgery. Hernias require additional surgeries which results in even greater expenses to the insurance company. Add to that the risk of potential complications with a large incision, and the choice is clear. Laparoscopic surgery is the only choice for me.

During my year of researching weight loss surgery, I also researched surgeons all over the United States. I was pleased to find that one of the premier bariatric surgeons in the country, Dr. J.K. Champion, is here in Georgia. In my research, I found that Dr. Champion’s qualifications are second to none. He has performed over 700 laparoscopic weight loss surgeries. He has written numerous surgical textbook chapters and actively publishes articles on advanced videoscopic surgical techniques he has developed or refined. He lectures and teaches extensively in the United States, Europe, and Asia. He is on the faculty of Mercer University School of Medicine and Emory University School of Medicine. Dr. Mark Fortson, my gastroenterologist physician, recommends and has referred me to use Dr. Champion stating that "Dr. Champion is the best of the best. I feel comfortable and confident referring you to him". With that said, no surgeon could possibly be more qualified.

In addition to his stellar qualifications, Dr. Champion has demonstrated a level of commitment to the health, well-being, and continued aftercare of his patients that most doctors would never even consider. He leads not one, but two (2) live support groups, an online support group, and a chat room for his patients. He has even hired a personal trainer to teach an exercise class for his patients, at no cost to the patient. Dr. Champion is highly qualified, highly skilled, highly experienced, and cares deeply about each and every one of his patients. For these reasons, he is my only choice for a surgeon.

Since Dr. Champion is not an in-network provider, and there is no in-network provider in my area that does the laparoscopic Roux-En-Y procedure, I respectfully request that you grant my request to cover my surgery with Dr. Champion at the in-network benefit. I thank you in advance for your kind consideration in this matter, and look forward to hearing from you in the very near future.

Sincerely,



Jane Doe