Tom gave permission for this post with email address included.  Any
helpful suggestions to give this appeal more power?  Arly Helm

Thomas Mooers [[log in to unmask]]

Blue Cross
Claims Department
P.O. Box 9062
Oxnard, CA 93031

RE:             Wesley Donald Forslund-Mooers, DOB: June 13, 2002
        Thomas C. Mooers, SSN: 552 55 6606

On July 12, 2002, Blue Cross communicated denial of coverage for a
prescription for human breast milk for my son, Wesley.  I am writing to
appeal that decision.

Wesley's mother (my wife) died three days after his birth.  She had
maintained a strong commitment to breastfeeding, for obvious health
reasons.  After her death, Wesley's pediatrician, Dr. John W. Reeder,
prescribed human milk from a breast milk bank.  (Attachment 1)

Breast milk is clearly medically necessary to ensure Wesley's health.
According to the American Academy of Pediatrics (an organization of
53,000 primary care pediatricians, pediatric medical subspecialists, and
pediatric surgical specialists), ".breast milk offers compelling
advantages to infants.These include health, nutritional, immunologic,
developmental, psychological, social, economic, and environmental
benefits."  (Attachment 2)

I seek coverage for the prescription, including reimbursement of costs
to date (attachment 3) and coverage for future costs.

In Wesley's case, breast milk is particularly important due to a family
history of Type 1 diabetes (his paternal grandfather).  Formula feeding
is a proven risk factor in development of diabetes.  Sources:
.       Borch-Johnson, K., et al., Relation between breastfeeding and
incidence of insulin-dependent diabetes mellitus. Lancet 2:1083-86
(1984) [It is postulated that insufficient breast-feeding of genetically
susceptible newborn infants may lead to beta-cell infection and IDDM
later in life.]
.       Gerstein HC; VanderMeulen J; The relationship between cow's milk
exposure and type 1 diabetes. Diabet Med 1996; 3(1): 23-9 / Medline ID:
96352125, ["There is a relationship between early cow's milk exposure
and the development of Type 1 diabetes in humans."]
.       Gerstein HC. Cow's milk exposure and type I diabetes mellitus. A
critical overview of the clinical literature. Diabetes Care1994; (1):
13-9 / Medline ID: 94155708,  ["Ecological and time-series studies
consistently showed a relationship between type I diabetes and either
cow's milk exposure or diminished breast-feeding.  In the case-control
studies, patients with type I diabetes were more likely to have been
breast-fed for < 3 months and to have been exposed to cow's milk before
4 months.  Early cow's milk exposure may be an important determinant of
subsequent type I diabetes and may increase the risk approximately 1.5
times."]
.       Mayer EJ, et al. Reduced risk of insulin-dependent diabetes
mellitus among breastfed children. Diabetes 37:1625-1632 (1988) [Formula
feeding accounts for as much as 26% of insulin dependent diabetes
mellitis in children.]
.       Verge CF, et al. Environmental factors in childhood IDDM. A
population-based, case-control study. Diabetes Care 17:1381-9 (1994)
[Study showed an increased risk of IDDM associated with early dietary
exposure to cow's milk-containing formula, short duration of exclusive
breast-feeding, and high intake of cow's milk protein in the recent
diet.]
.       Virtanen SM, et al. Early introduction of dairy products
associated with increased risk of IDDM in Finnish children. Diabetes
42:1786-90 (1993). [Introduction of cow's milk-based formula a
significant risk factor in IDDM.]

Additional disadvantages of formula instead of breast milk are well
documented.  For example, formula fed infants get more, and get more
severe, infections.  Sources:
.       Borgnolo G, et al. A case-control study of Salmonella
gastrointestinal infection in Italian children. Acta Paediatr 85:804-8
(1996) [Not breastfeeding was the single most important factor
associated with a 5-fold increased risk of Salmonella infection.]
.       Beaudry M, et al. Relation between infant feeding and infections
during the first six months of life. J Pediatr 126:191-7 (1995) [Not
breastfeeding substantially increased risk of respiratory and
gastrointestinal infections in first six months of life.]
.       Aniansson, G et al. A prospective cohort study on breastfeeding
and otitis media in Swedish Infants. Pediatr Infect Dis. J. 13:183-88
(1994) [Acute otitis media frequency was significantly higher in the
non-breastfed children in each age group (2,6, and 10 months of age);
the frequency of upper respiratory infections was also increased in
those children, but reduced in the breastfed group.]
.       Lerman, Y. et al. Epidemiology of acute diarrheal diseases in
children in a high standard of living rural settlement in Israel.
Pediatr. Infect. Dis. J. 13(2):116-22 (1994) [Children less than 12
months of age had a higher incidence of acute diarrheal diseases during
the months they were being formula-fed than children who were breastfed
during the same period.]
.       Pisacane A; Graziano L; Zona G; Granata G; Dolezalova H; Cafiero
M; Coppola A; Scarpellino B; Ummarino M; Mazzarella G; Breast feeding
and acute lower respiratory infection. 83 Acta Paediatr 714-18 (1994)
[not breastfeeding is a strong risk factor for acute lower respiratory
infection (i.e., pneumonia and bronchitis) in industrialized countries]
.       Harabuchi, Y. et al. Human Milk secretory IgA antibody to
nontypeable Haemophilus influenzae: possible protective effects against
nasopharyngeal colonization. J. Pediatr. 124:193-98 (1994) [Formula
lacks specific secretory IgA antibody present in breastmilk, suggests a
mechanism by which formula-fed infants have higher incidence of
infection.]
.       Howie PW, et al. Protective effect of breastfeeding against
infection. BMJ 300:11-16, 1990. [The added risk of formula-feeding can
account for 7% of all infants hospitalized for respiratory infections.]
.       Duffy LC, et al. The effects of infant feeding on
rotavirus-induced gastroenteritis: a prospective study. Am J Pub Health
76:259-263 (1986). [In industrialized nations, formula-fed infants have
a 3-4 fold risk of diarrheal illness.  Moderate to severe rotavirus
gastroenteritis is five times more common in formula-fed infants.]
.       Cochi SL, et al. Primary invasive Haemophilus influenza b
disease: a population based assessment of risk factors. J. Pediatr.
108:887-896 (1986). [A 4-16 fold higher risk exists for H influenzae
bacteremia and meningitis in North American formula-fed babies.]

Children who were formula-fed score lower on indices of neurological
development than do children who were breastfed.  Sources:
.       Wang YS, Wu SY. The effect of exclusive breastfeeding on
development and incidence of infection in infants. J Hum Lact 12:27-30
(1996) [Normal fullterm infants studied during the first year after
birth.  Those exclusively breastfed for the first four months differed
significantly from those not exclusively breastfed: at one year, the
artificially-fed group showed less advanced. Personal-Social and gross
motor development on the Denver Developmental Screening Test, and higher
cumulative incidence of infectious diseases.]
.       Pollock, J.I. Long-term associations with infant feeding in a
clinically advantaged population of babies. Dev. Med. Child Neurol.
36(5);429-40 (1994) [Some aspects of intellectual attainment at five and
ten years of age can be demonstrated to be inferior among children who
were formula-fed compared with those that were exclusively breastfed for
at least three months.]
.       Morley R., et al. Mother's choice to provide breastmilk and
developmental outcome. Arch Dis Child 63:1382-1385 (1988). [Formula-fed
preterm infants had lower Bayley Mental Develpment scores at 18 months,
even after adjusting for social and demographic influence.]
.       Morrow-Tlucak, M, et al., Breastfeeding and cognitive
development in the first two years of life. Soc Sci Med 26:635-639
(1988). [Scores on the Bayley Mental Development Index were lower in
formula-fed at 1-2 years of age, and scores were directly correlated
with duration of breastfeeding.]
.       Bauer G, et al. Breastfeeding and cognitive development of
three-year-old children. Psychological Reports 68:1218 (1991). [Scores
on the McCarthy Scales of Children's Abilities were significantly lower
at three years of age as the duration of breastfeeding decreased.]
.       Taylor B, et al. Breastfeeding and child development at five
years. Dev Med Child Neurol 26:73-80 (1984). [Formula-fed children
showed reduced performance on developmental tests at age five years.]
.       Lucas, A. et al. Breast milk and subsequent intelligence
quotient in children born preterm. Lancet 1992;33;261-62. [Formula-fed
preterm infants had lower IQ scores at age 7-8 years than preemies fed
expressed breastmilk; the association held after controlling for
mother's education and social class, and regardless of whether the
mother attempted to express milk and failed or never attempted to
express milk.]

There is a higher incidence of allergies among formula-fed children.
Sources:
.       Saarinen UM, Kajosaari M. Breastfeeding as prophylaxis against
atopic disease: prospective follow-up study until 17 years old. Lancet
1995; 346:1065-69. ["We conclude that breastfeeding is prophylactic
against atopic disease, the effect extending into early adulthood.
Breastfeeding for longer than 1 month without other milk supplements
offers significant prophylaxis against food allergy at 3 years of age,
and also against respiratory allergy at 17 years of age.  Six months of
breastfeeding is required to prevent eczema during the first 3 years,
and possibly also to prevent substantial atopy in adolescence."  The
article also states that the differences by infant feeding method were
so pronounced that it "suggested an influence of early milk feeding that
may exceed the heredity burden."]
.       van den Bogaard C; van den Hoogen HJ; Huygen FJ; van Weel C; Is
the breast best for children with a family history of atopy? The
relation between way of feeding and early childhood morbidity. 25 Fam
Med 471-45 (1993) [In families with a history of allergies, not
breastfeeding was related to higher levels of childhood illness both in
the first and the first three years of life.  In the first year of life
they had more episodes of gastroenteritis, lower respiratory tract
infections, and digestive tract disorders.  Over the next three years of
life they had more respiratory tract infections and skin infections.]
.       Merrett TG, et al. Infant feeding and allergy: twelve-month
prospective study of 500 babies born in allergic families. Ann Allergy
61:13-20, 1988. [Formula feeding is associated with higher incidence of
wheezing, diarrhea, vomiting, and prolonged colds.]
.       Israel D, et al., Protein induced allergic (PAC) colitis in
infants. Pediatr. Res. 25:116A, 1989. [PAC is associated with
formula-feeding and supplementation.]

Formula-fed children have a higher incidence of certain cancers.
Sources:
.       Schwartzbaum, J. et al. An exploratory study of environmental
and medical factors potentially related to childhood cancer. Med &
Pediat Oncology 19(2): 115-21 (1991).
.       Davies, M. et al. Infant feeding and childhood lymphomas
[cancer]. Lancet 2:365-368 (1988). [There was as much as an 8 fold
increase in risk of developing lymphomas among children artificially fed
or breastfed less than six months.]

Formula Feeding is a risk factor in Crohn's disease and ulcerative
colitis.  Sources:
.       Rigas A, et al. Breast-feeding and maternal smoking in the
etiology of Crohn's disease and ulcerative colitis in childhood. Ann
Epidemiol 3:387-92 (1993) [Lack of breastfeeding was associated with
higher rates of inflammatory bowel disease in children and adolescents.]

.       Koletzko S., et al. Role of infant feeding practices in
development of Crohn's disease in childhood. Br. Med. J. 298:1617-18
(1989)
.       Bergstrand O; Hellers G. Breast-feeding during infancy in
patients who later develop Crohn's disease. Scand J Gastroenterol
18:903-6 (1983) [Lack of breastfeeding appears to be a risk factor in
development of Crohn's disease.]

In summary, the prescription is necessary to ensure Wesley's health, and
it is supported by his pediatrician.  The alternative is to risk
increased likelihood of Type 1 diabetes, infection, lower on indices of
neurological development, allergies, cancer, Crohn's disease, and
ulcerative colitis.  Of course Wes will loses a lot with the death of
his mother.  He should not suffer additional risk to his health.  It's
why we have insurance in the first place.

Thank you,


Thomas C. Mooers

cc
Department of Managed Health Care
California HMO Help Center
980 Ninth Street, Suite 500
Sacramento, CA 95814-2725

State of California, Department of Corporations
Health Care Division
3700 Wilshire Blvd
Los Angeles CA 90010-3001

Insurance Commissioner
Insurance Department
300 Capitol Mall, Suite 1500
Sacramento, CA 95814



AMERICAN ACADEMY OF PEDIATRICS Policy Statement on Breastfeeding and the
Use of Human Milk (RE9729), Pediatrics 100(6):1035-1039, Dec 97
[text follows]

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