What Do You Think? Letter Of Medical Necessity

[Ready4success 380]

Hey everybody,

I have been stressing over how to approach the subject of the sleeve with my PCP who is a huge advocate for the band. I've come to the end of the process and the only thing standing between me and insurance approval is the freaking letter of medical necessity for Cigna. Here are some ideas I'm thinking about on how to sway my PCP at my appt next week:

1. Bring the surgery packet my surgeon gave me that outlines the differences between the two surgeries, and show her how the sleeve is better for me(I have Type II DM and HTN and as far as I know, the band doesn't do as well of a job resolving these issues as the sleeve).

2. Type up a letter as a guide (i.e. listing my height, weight, bmi, co-morbidities, stating the surgery is medically necessary, and that I'm cleared from a medical standpoint for surgery, yada, yada, yada).

I sound like a really anal person, and I'm not, but I just have a gut feeling that since everything in this process has been so easy, this will be the part that gets screwed up. What do you guys think? Should I just let my PCP do her thing, and HOPE that Cigna will be okay with whatever she submits?

Thanks,

Kim

[O.T.R. sleever 3,386]

If she will provide the recommendation for the sleeve then let her do her thing.

If she tries pushing the Lapland you can easily point out the huge failure rate of the band along with the success rate of sleeving.

Not to mention, how many band to sleeve revisions are being done, I for one dont want to set myself up for a second surgery.

And on top of this I wouldn't want the foreign object in my body, nor would I want to deal with the ongoing hassle & cost of maintaining the band.

[babygirl_sandy 85]

I had the same task for my insurance and i chose to write up my own letter and take it to my appt with my PCP. He was actually happy that he had a starter letter and he could always add or delete what he felt would be needed for an approval.. He was very clear that he could not be specific as to what surgery i should get but he could write that the surgery was medically necessary. Only the Surgeon can specify what surgery is right for you.. SO this is my sample letter I took in as my ice breaker and he really appreciated it.. Hope this helps!!

June 29, 2012

RE: Name XXXXXX

DOB: XX/XX/XXXX

Medicare ID# XXXXXXXX

Medicaid ID# XXXXXXXX

To whom it may concern,

This letter is in support of bariatric surgery for XXXXXXXXXXX. I have been Ms. XXXXXXXXX’s primary care physician for over XX years. The patient has been overweight since she was first seen in my office. I am referring her now for bariatric surgery as all non-surgical options have been unsuccessful and feel this is a medically necessary procedure to help her with her morbid obesity diagnose and co-morbidities.

Ms. XXXXX has tried multiple times to change her diet and increase exercise but with no success. She has been seeing a nutritionist through her Urologist specialist to help her maintain her current weight, which is considered Morbidly obese. In addition to morbid obesity, Ms. XXXXX is suffering from the following co-morbid conditions: Hypertension, Stress incontinence, Low back and lower extremity pain, edema, shortness of breath on exertion. Ect....

Ms. XXXXXX has been obese for XX years and morbidly obese for XX years with all the weight ups and downs she has endured throughout her adult life. She is X-X” tall, weighs XXX pounds and has a BMI of XX.X she has tried multiple weight management programs including Weight watchers, Slim fast , La weight loss, Fasting, liquid diet, Green tea diet, Atkins, Over the counter diet pills. Some were even attempted more than once however she has not lost enough weight to resolve her morbid obesity. Additionally, she cannot sustain the weight loss that occurred on diet regimens and has gained the weight back or even more. She is limited due to her co-morbidities and her ability to exercise. Her family medical history is significant for both maternal and paternal for obesity, hypertension, heart disease, and diabetes.

I believe Ms. XXXXXXX has tried many non-surgical methods of weight loss with limited success and has continued to struggle to re frame from gaining more weight. I am in favor and support her decision for a surgical treatment option. I feel bariatric surgery could eliminate and significantly improve many of her current health problems as well as her overall lifelong health. I strongly urge you grant XXXXXXXXXXXX’s request for bariatric surgery for treatment of obesity.

I trust this information will aide you in understanding the true severity of Ms. XXXXXXX case and in facilitating the proper assessment. Please feel free to contact me if I can answer or clarify any questions you might have.

Sincerely,

Dr. XXXXXXXXXXX

[IMSKINNY 160]

Great letter!!

[babygirl_sandy 85]

Great letter!!

Thanks.. Fingers cross and heart on the edge that this works.. I hope it helps her on her journey for approval..

Sent from my SPH-D710 using VST

[Ready4success 380]

If she will provide the recommendation for the sleeve then let her do her thing.

If she tries pushing the Lapland you can easily point out the huge failure rate of the band along with the success rate of sleeving.

Not to mention' date=' how many band to sleeve revisions are being done, I for one dont want to set myself up for a second surgery.

And on top of this I wouldn't want the foreign object in my body, nor would I want to deal with the ongoing hassle & cost of maintaining the band.[/quote']

I agree, I've heard of too many erosions and I have too much to lose for the band. Thanks

[Ready4success 380]

I had the same task for my insurance and i chose to write up my own letter and take it to my appt with my PCP. He was actually happy that he had a starter letter and he could always add or delete what he felt would be needed for an approval.. He was very clear that he could not be specific as to what surgery i should get but he could write that the surgery was medically necessary. Only the Surgeon can specify what surgery is right for you.. SO this is my sample letter I took in as my ice breaker and he really appreciated it.. Hope this helps!!

June 29' date=' 2012

RE: Name XXXXXX

DOB: XX/XX/XXXX

Medicare ID# XXXXXXXX

Medicaid ID# XXXXXXXX

To whom it may concern,

This letter is in support of bariatric surgery for XXXXXXXXXXX. I have been Ms. XXXXXXXXX’s primary care physician for over XX years. The patient has been overweight since she was first seen in my office. I am referring her now for bariatric surgery as all non-surgical options have been unsuccessful and feel this is a medically necessary procedure to help her with her morbid obesity diagnose and co-morbidities.

Ms. XXXXX has tried multiple times to change her diet and increase exercise but with no success. She has been seeing a nutritionist through her Urologist specialist to help her maintain her current weight, which is considered Morbidly obese. In addition to morbid obesity, Ms. XXXXX is suffering from the following co-morbid conditions: Hypertension, Stress incontinence, Low back and lower extremity pain, edema, shortness of breath on exertion. Ect....

Ms. XXXXXX has been obese for XX years and morbidly obese for XX years with all the weight ups and downs she has endured throughout her adult life. She is X-X” tall, weighs XXX pounds and has a BMI of XX.X she has tried multiple weight management programs including Weight watchers, Slim fast , La weight loss, Fasting, liquid diet, Green tea diet, Atkins, Over the counter diet pills. Some were even attempted more than once however she has not lost enough weight to resolve her morbid obesity. Additionally, she cannot sustain the weight loss that occurred on diet regimens and has gained the weight back or even more. She is limited due to her co-morbidities and her ability to exercise. Her family medical history is significant for both maternal and paternal for obesity, hypertension, heart disease, and diabetes.

I believe Ms. XXXXXXX has tried many non-surgical methods of weight loss with limited success and has continued to struggle to re frame from gaining more weight. I am in favor and support her decision for a surgical treatment option. I feel bariatric surgery could eliminate and significantly improve many of her current health problems as well as her overall lifelong health. I strongly urge you grant XXXXXXXXXXXX’s request for bariatric surgery for treatment of obesity.

I trust this information will aide you in understanding the true severity of Ms. XXXXXXX case and in facilitating the proper assessment. Please feel free to contact me if I can answer or clarify any questions you might have.

Sincerely,

Dr. XXXXXXXXXXX[/quote']

Thank you so much! This is a huge help. My PCP is really nice and understanding, for someone who probably has never weighed more than 100lbs in her life (she's a tiny Asian lady). I just didn't want to overstep my boundaries, but the way you worded your letter is perfect. Thank you!

[babygirl_sandy 85]

Thank you so much! This is a huge help. My PCP is really nice and understanding' date=' for someone who probably has never weighed more than 100lbs in her life (she's a tiny Asian lady). I just didn't want to overstep my boundaries, but the way you worded your letter is perfect. Thank you![/quote']

I'm glad I was able to help, and he also stated that if you are currently seeing any specialist for stomach problems like acid reflux.. Ect.. A letter from that Dr will also help.. Good luck!!

Sent from my SPH-D710 using VST