Letter of Medical Necessity

[emily_0192010 168]

Hey everyone! It has been a while since I've posted but the real world has been crazy insane recently! So, I am done my three-months PSWL and all my ducks are in order to submit for approval except for one. I went to my PCP for my letter. The FIRST visit she was all "i need all of your records from the surgeons office before i'll consider it". SO, I had all my stuff faxed over and I had to make a second appointment. At that appointment she finally agreed to write the letter. In other words, to me she said that she agreed to write the letter of medical necessity. BUT it would have to wait until her office person was back before it would be done. I wait about a week and half, and finally it is done and it is faxed over to the surgeons office. The surgeons office calls me "it isn't what we need. i called and they refuse to put that it is medically necessary into the letter".

So what do I do now? I can't afford to go "doctor shopping" to find a doctor that will write the letter for me. I meet all of Aetna's guidelines, and I do have a letter from my PCP they just will not write that it is medically necessary. So do I submit to Aetna anyways or... I don't know.

Any help??

Thanks!

[Khy 16]

I guess that depends on what your Aetna says. I had Aetna but I didn't have a letter of medical necessity. I had records of my weight from the PCP but that is about all. I would say file without it. Aetna will let you know if they want or need such a thing.

Khy

[emily_0192010 168]

I guess that depends on what your Aetna says. I had Aetna but I didn't have a letter of medical necessity. I had records of my weight from the PCP but that is about all. I would say file without it. Aetna will let you know if they want or need such a thing.

Khy

Thanks! It doesn't say anything about a letter of medical necessity in their policy bulletin, so I am hoping that it isn't necessary. I qualify under all of their other guidelines so hopefully that is enough! They submitted to my insurance either today or tomorrow so I guess I will find out soon enough!

[longer-life 139]

Thanks! It doesn't say anything about a letter of medical necessity in their policy bulletin.

I also have Aetna (PPO) and the bulletin I read doesn't mention it either. I don't know if bulletins change depending on the plan.

Just curious, did you do the 3 month diet plan with your PCP?

Best wishes! Keep us updated.

[CT Fats 82]

I've got Aetna (ppo) as well. Im hoping that a letter of neccesity isn't required. I did the 3 month NUT appointments, the tests and I have sleep apnea. All they asked for so far was proof that I have been overweight for at least 3 years. I hope thats enough.

[longer-life 139]

I forgot to mention my surgeon did ask for a letter of medical necessity even though it is not mentioned on the bulletin I read.

All they asked for so far was proof that I have been overweight for at least 3 years. I hope thats enough.

I was "only" asked for 2009 & 2010 AND I was told I could do the 3 month plan with my PCP, not with a NUT, as the bulletin mentions. hmmm I just contacted my insurance coordinator, lets see what she says.

[emily_0192010 168]

I also have Aetna (PPO) and the bulletin I read doesn't mention it either. I don't know if bulletins change depending on the plan.

Just curious, did you do the 3 month diet plan with your PCP?

Best wishes! Keep us updated.

I did three months through my surgeon's office. I went twice a month to get weighed in and "chat" with the diet counselor. I also had to see a nutritionist and have a psych clearance.I wasn't required to do any special testing, just the pre-op bloodwork, chest xray and ekg.

[emily_0192010 168]

I've got Aetna (ppo) as well. Im hoping that a letter of neccesity isn't required. I did the 3 month NUT appointments, the tests and I have sleep apnea. All they asked for so far was proof that I have been overweight for at least 3 years. I hope thats enough.

It is very interesting... my surgeon's office wanted a 5 year weight history, which I didn't have. I only have 3. Before that I didn't have insurance and since I was lucky enough not to be sick at all I never went to a clinic or anything. I did notice that the bulletin was recently (the last couple years) updated and it changed to only requiring a two-year history. So I think three is good.

I'm starting to think that the letter is one of those things that would make it easier to get approved but isn't a "must have".

[longer-life 139]

I'm starting to think that the letter is one of those things that would make it easier to get approved but isn't a "must have".

I hope you are right. I was asked to go to 1 appointment with a NUT, 3 with my PCP and a pysch clearance. No chats with a diet counselor or the like. Ugh! It's worrisome.

[longer-life 139]

I noticed we are in the same city. Who will be your surgeon? I am leaning towards Dr. Marema in St. Augustine.

[emily_0192010 168]

I noticed we are in the same city. Who will be your surgeon? I am leaning towards Dr. Marema in St. Augustine.

I chose to go with Dr. Pinnar here in Jax. He is partners with Dr. Cywes and i'll be having the surgery at Memorial. They mostly work with band patients but I had a long discussion with him about why I wanted the sleeve and he respected those and didn't push for the band. I didn't "doctor shop" too much as I needed to stay close to home but I feel very comfortable with him and I know one other person who had him as their surgeon so I'm confidant that everything will go well.

Where in Jax are you?

[CT Fats 82]

It is worrisome being this close and having your file in the hands of someone who doesn't know what you've been through making the decision. I forgot, i had to go the psych eval too.

[longer-life 139]

I'm on Southside. You?

[emily_0192010 168]

Not far from there! I'm in Mandarin off of San Jose!

[longer-life 139]

Not far at all. I'm in that area all the time. You are ahead of me. I saw my PCP for the first time yesterday. Let's keep in touch!