I respectfully request that you allow benefits to be paid for Gastric Bypass Surgery and related expenses prior to and following surgery. This letter will provide evidence that this surgery is medically necessary for me.

I am a smart person. I consider myself to have a very high IQ. I have a liberal arts degree, a master’s degree and almost a second master’s degree. I can solve most of the problems life presents me either on my own or with the help of my parents. I have the ideal job, and most aspects of my life are in order and moving in the right direction.WHY, then, can I not lose weight? It infuriates me. A smart, in-control person like me should be able to lose weight. Yet I just sit back, almost outside of my own body, and watch myself stay fat and get fatter.

I have been somewhat able to live life vicariously through my two size-4 sisters. This has served to either make me happy, or usually just make me more frustrated and jealous of them. As far as living my own life, I am waiting until I "get skinny" to experience life. I don’t enjoy being in social situations outside of my "comfort zone," because I have a "disparagement of [my] body image, a condition in which persons feel that their body is grotesque and loathsome. [I] believe that others view [me] with hostility and contempt, which makes [me] self-conscious and impairs [my] social functioning" (http://www.merck.com/pubs/mmanual/section1/chapter5/5a.htm). I have NEVER been on a date, even kissed a boy. I am not even pursuing a mate, though I strongly desire being married and starting a family. Who would want me like this? Why even bother? I will soon be thirty years old. I don’t have much longer to wait to get skinny. I will be an old maid soon. A study documented in a WebMD article "Obesity and Being Overweight," that followed obese adolescents for 7 years found that overweight women "were 20% less likely to be married" (http://my.webmd.com/content/article/1680.51096) than their normal-weight peers.

I find myself retreating even further into the safeness of my own world--my family and a few friends at work. Those people that don’t judge me or give me any grief about my size. I do not speak out in social situations by expressing my viewpoint as long as I am outside of my comfort zone. I often feel upset with myself when someone else makes an astounding revelation that I had in my head just a moment earlier (this happens often). I live in fear that someone will make a negative comment about my weight, and I have only in recent years been able to talk about being overweight myself.

According to the Alvarado Center for Surgical Weight Control, "the belief that Morbidly Obese patients can control their weight by restricted intake and altered behavior is illusory, and leads to a failure of medical therapy, not a failure of will power" (http://www.gastricbypass.com/Gastric%20Bypass-for%20Doctors%20Only.html). The medical field is failing in offering only the traditional weight loss options to people who are morbidly obese. The medical profession dismisses the failure of traditional programs as lack of success and willpower of the morbidly obese person.

I have been a member of several structured weight-loss plans, including a visit to a registered dietician and participation in Weight Watchers. In both instances I lost some weight before dropping out of the programs, either because of the patronizing attitude of the facilitators, or the inconvenience of sticking to the meal plan. The weight loss plans that have worked best for me have been the ones carried out by me, including keeping a journal of calories and fat consumed and exercise done. One summer, I was gung-ho about swimming laps at the community pool. Another summer, I walked around the apartment parking lot on a twice-daily basis. One summer, I limited my calories to ~800 a day and my fat to ~10-15 grams a day. I lost down to 205 pounds. When I stopped, I gained the 25 pounds back plus about 15 more.

I have also used weight-loss drugs to aid in my weight loss. I cannot take over-the-counter diet drugs and any prescription diet drugs I took had to be closely monitored by my doctor because of possible interactions with my other medications. My endocrinologist in Knoxville set up an appointment for me to visit a doctor in Asheville, North Carolina to receive a prescription for Fen-Phen®, as it could not yet be prescribed in my state. I stopped taking it shortly after it was prescribed due to the heart problems the drug reportedly caused. I have a $300 bottle of Meridia® in my medicine cabinet. I haven’t been taking the pills, because for them to work, one still has to exercise and diet.

I find myself, possibly because of things I learned about behavior in the psychology classes I took, or my obsession with weight loss, unable to do either of these anymore."Dietary weight loss attempts often cause depression, anxiety, irritability, weakness and preoccupation with food" (http://www.asbs.org/html/ration.html). Each time I go on a diet and come back off of it, I slip further and further into psychosis about weight loss. I have less willpower and more ability to rationalize eating anything at any moment--i.e.-everyone else is doing it, I can eat less later, if I count this as a meal and eat nothing else, who cares if I’m fat"...

I have not always been grotesquely morbidly obese. Up until the beginning of third grade, I was unusually small and skinny with long blond hair.In October of 1980, I had surgery to remove a craniopharyngioma. I gained weight immediately after surgery and lived life as a moderately overweight person until the tumor recurred and I had brain surgery again for the craniopharyngioma in 1987. Since that surgery, my weight has increased at an exponential rate, despite my continuous involvement in programs of exercise, diet and diet drugs. The National Cancer Institute defines a craniopharyngioma (KRAY-nee-o-fah-rin-jee-O-ma) as a "type of brain tumor that develops in the region of the pituitary gland near the hypothalamus, the area of the brain that controls body temperature, HUNGER, and thirst. These tumors are usually benign, but are sometimes considered malignant because they can press on or damage the hypothalamus and affect vital functions" (http://www.telemedical.com/Telemedical/Library/Diseases/Brain_Tumors.htm. Craniopharyngioma is a cause of pituitary hypofunction.Weight is determined by communication between the brain and the stomach and other digestive organs. One's eating patterns and knowing when the body is hungry are determined by "feeding and satiety centers located in the hypothalamus and pituitary glands of the brain that respond to signals indicating high fat stores and hunger" (http://my.webmd.com/printing/article/1680.51096). Tumors affecting this region of the brain, most commonly the craniopharyngioma, may affect the hypothalamic regulation of hunger and satiety. Craniopharyngiomas "give rise to the ventromedial syndrome of hyperphagia, which leads to obesity" (http://professional-content.webmd.com/sam/navig/sam_article.asp?article=article://3882.0903&query=%22stewart%20agras%22&highlight=t#hit). Hyperphagia refers to "overeating. The term is most often used for a syndrome, induced by a lesion in the ventromedial areas of the hypothalamus"resulting in excessive intake of foodstuffs, increased accumulation of adipose tissue and obesity." (The Penguin Dictionary of Psychology, © Arthur S. Reber, 1995).The "final common pathway to caloric balance lies in behavior mediated by the CNS" (http://www.merck.com/pubs/mmanual/section1/chapter5/5a.htm), regardless of the other factors affecting and aggravating my obesity.

Though I can link my obesity with being a result of my surgeries for craniopharyngiomas and the subsequent hypothalamic impairment, there is no way to reverse the weight I gained because of the surgeries. The surgeries and my resulting diets and ever-increasing preoccupation with food have resulted in my fat self. And I have to live with the fat. When I’m in a social situation, no one cares HOW I got fat. All that matters is that I AM. It used to be easy to just cross my arms and buckle up and say, "It’s not my fault.I can’t do anything about being fat."Well, it’s not going away.

At 5’1" tall and 250 pounds, I have a Body Mass Index (BMI) of 47. Severe morbid obesity is "defined as a body mass index >40 kg/m²" characterized by a weight which is at least 100 pounds or twice the ideal weight for frame, age, height and sex," according to the BlueCross BlueShield of Tennessee Medical Policy Manual (http://www.bcbst.com/MPManual/Bariatric_Surgery_for_Morbid_Obesity.htm). Waist circumference higher than 35 inches for females "signifies increased risk for heart disease, diabetes and impaired functioning.Distribution of body fat around the abdomen and hips may be a further indication of risk" (http://my.webmd.com/content/article/1680.51096). My waist is 42 or 44 at last measurement, and I have a large "spare tire" of fat around my abdomen, placing me in a position of worse health because of being fat.

Obesity is associated with increased mortality, perhaps 2-8 times that of an average-weighted person (http://www.gastricbypass.com/Gastric%20Bypass-for%20Doctors%20Only.html). Being fat also adversely affects my health in the areas of artherosclerotic cardiovascular disease and respiratory disease, in addition to the social diseases of depression and discrimination I discussed earlier.Artherosclerotic cardiovascular disease manifests itself in a number of ways, including hypertriglyceridemia, hypercholesterolemia, hypertension, and ultimately heart disease or heart failure (http://www.gastricbypass.com/Gastric%20Bypass-for%20Doctors%20Only.html). I have had instances of slightly elevated triglyceride and cholesterol levels on my routine doctor visits, but never high blood pressure or signs of heart disease. The expressions of respiratory disease in morbidly obese people include asthma, respiratory insufficiency and sleep apnea (http://www.gastricbypass.com/Gastric%20Bypass-for%20Doctors%20Only.html). My mother and sisters have told me that I often stop breathing at night when I am sleeping. Mom has become scared on occasion and wanted to awake me to make sure I was all right.Sleep apnea is characterized by "the upper throat relaxing and collapsing at intervals during sleep, thereby temporarily blocking the passage of air" (http://my.webmd.com/content/article/1680.51096). Because of my sleep-apnea symptoms, I do not get adequate rest at night. I am often sleepy through the day. I do not have any other respiratory deficiencies to my knowledge.

Another co-morbidity I experience because of being severely obese is chronic edema and swelling.Taking thyroid and corticosteroid medications causes one to retain water. I take both of these medicines for required hormone replacement therapy as a result of my surgeries. I have stretch marks around my abdomen and calves as a result of the edema and weight gain caused by these medications. I have not been able to wear shorts without socks pulled way up to my knees to hide them since these stretch marks appeared. I try to get tanned every summer to camouflage them a little bit, but fat does not tan.

The medicines I take and their side effects (according to MedLine Drug Information) are listed below:

1. DECADRON--MedLine Drug Information: Corticosteroids Glucocorticoid Effects (Systemic) http://www.nlm.nih.gov/medlineplus/druginfo/corticosteroidsglucocorticoide202018.html
   1. reddish purple lines on arms, face, groin, legs, or trunk
   2. trouble in sleeping
   3. weight gain (rapid)
2. LEVOXYL--MedLine Drug Information: Thyroid Hormones (Systemic) http://www.nlm.nih.gov/medlineplus/druginfo/thyroidhormonessystemic202566.html
   1. dry, puffy skin
   2. weight gain
3. ESTRADIOL PATCHES--MedLine Drug Information: Estrogens http://www.nlm.nih.gov/medlineplus/druginfo/estrogenssystemic202226.html
   weight gain (rapid)
4. MEDROXYPROGESTERONE--MedLine Drug Information: Progestins for Noncontraceptive Use (Systemic) http://www.nlm.nih.gov/medlineplus/druginfo/progestinsfornoncontraceptiveu202758.html
   1. unusual or rapid weight gain
   2. trouble in sleeping
5. DDAVP--WebMD Drug Information: Desmopressin (Systemic) http://www.webmd.com/drugs/mono-112-DESMOPRESSIN+-+NASAL+SOLUTION.aspx?drugid=16777&drugname=DDAVP+Nasl
   weight gain (rapid)

Of the five prescription medications I take for hormone replacement necessitated by my craniopharyngioma surgeries, all five cause weight gain as a side effect.Two of the medicines cause trouble sleeping, a problem aggravated by or adding to my sleep-apnea symptoms.Decadron, the cortisone-like medicine I take, causes reddish purple lines on arms, legs, or trunk, explaining the stretch marks on my legs and abdomen.Levoxyl, the thyroid medicine I take, causes puffy skin, making me look even fatter.

As I discussed earlier, I am ready to stop living life as a morbidly obese woman and start having the life I want to have. I discussed the facts that I am definitely morbidly obese and suffer daily because of it.Whether my morbid obesity is caused by the effect of my craniopharyngioma surgeries on my hypothalamic function, the side effects of the medications I take, or my overeating caused by my ever-increasing preoccupation with food, it prevents me from being happy--from living life. I have proven that I, not unlike other morbidly obese individuals, am not able to lose the weight through programs of diet, exercise or diet drugs. In fact, "it’s clear that nonoperative treatment doesn’t work for the severely obese" In this group, the failure rate of dieting approaches 100%" (http://my.webmd.com/content/article/1689.51239). I have done everything in my power to lose weight so I can start a normal life--diet, exercise and diet drugs (and combinations of all three)--only to fall further and further into the diet neurosis. Here I am less and less able to control my weight, and I watch my weight increase or, at best, stay the same. I try every idea I have to help me lose weight. I have not been able to shed the pounds by running across America like Forrest Gump did, and a genie to grant me the wish of trading bodies with Jennifer Aniston has not appeared yet.Of the feasible weight-loss options I have tried, none have proven successful for the duration.

One weight-loss option I have not yet tried is weight loss surgery, which the Mayo Clinic finds "effective in obtaining a durable weight loss over four years [as well as] an overall improvement in quality of life" (http://www.mayo.edu/comm/mcr/news/news_1226.html). The BlueCross BlueShield Policy Manual defines medical appropriateness for surgery for morbid obesity by the following three factors:

1. Morbid obesity is defined as at least 45 kg (100 pounds) over the ideal weight or at least twice the ideal weight.
2. (BMI) of >40 kg/m²
3. Condition of morbid obesity of at least 5 years duration with physician supervised multiple documented failed weight loss attempts (http://www.bcbst.com/MPManual/Bariatric_Surgery_for_Morbid_Obesity.htm).

The National Institute of Health has established the following standards and guidelines for medical appropriateness. The NIH says a candidate should:

1. be at least 100 pounds over ideal body weight
2. have a Body Mass Index (BMI) over 40
3. and have no significant contraindications to surgery (http://www.adoctorinyourhouse.com/morbid_obesity/weight_loss_surgery/candidate.html)

I have indicated in this exposition that I meet all of these criteria: 1) I am at least 100 pounds of my ideal weight (actually 125 pounds over ideal); 2) I have a BMI of 47; and 3) I have been participating in weight-loss regimens since 1980. Surgery for weight loss, according to the American Society for Bariatric Surgery, is "medically necessary because it is the only proven method of achieving long-term weight control for the morbidly obese" (http://www.asbs.org/html/ration.html). When morbid obesity threatens life, "the only effective and long-term therapy is surgical treatment" (http://www.gastricbypass.com/Gastric%20Bypass-for%20Doctors%20Only.html), specifically Gastric Bypass Surgery. The gastric bypass works by making the intestines less efficient in absorbing food. Thus, it is a malabsorptive procedure (http://www.utmedicalgroup.com/pages/top_obesity.html). Laparoscopic gastric bypass surgery is becoming more widespread in the field of bariatric surgery.Laparoscopy was proven a safe method of weight-loss surgery at a recent Endocrine Society meeting in Toronto (http://www.physiciansweekly.com/archive/00/08_28_00/itn1.html). Laparoscopic gastric bypass is the desired surgical procedure for me, and likely it will be used on a more widespread basis in the future.Laparoscopic gastric bypass appears to be safe and effective in the treatment of severe or morbid obesity, though it is more technically challenging for doctors to perform (Wei-Jei Lee, MD, et al. Laparoscopic Versus Open-Banded Gastroplasty for the Treatment of Morbid Obesity. Surgical Laparoscopy, Endoscopy & Percutaneous Techniques 2001; 11:9-13). Surgeons must be skilled in both gastric bypass and laparoscopic procedures to perform this surgery.

After living 21 years as a fat person, I am ready to do something, anything, to begin my life. I am so tired of being depressed all the time and constantly being asked by my family, "What’s wrong?" or "Are you depressed?"Of course they know, but they work so hard to keep my spirits up. I am tired of being fat. I am MAD!I am depressed!Life is passing me by while I sit and watch myself get fatter and fatter. Diets and diet drugs and exercise clearly do not work with a person of my morbid obesity. My two surgeries to the hypothalamic region of my brain provide evidence that my body’s hunger and satiety center malfunctions, causing hyperphagia or overeating. My co-morbidities alone, those of increased mortality, borderline-cardiovascular disease and respiratory disease, in addition to the social diseases of depression and discrimination, warrant that major action be taken to reduce my weight.Having weight loss surgery now will prove much more lucrative and economical than having corrective surgeries my co-morbidities will inevitably necessitate in the future.Gastric Bypass Weight Loss Surgery will give me the chance to start living.