Letter of medical necessity

losin'it · April 2, 2007

Hi~

I have Oxford Freedom Municipality and I called them to be sure that I have no exclusions on my policy and THANKFULLY I don't. They said that all I need is a letter of medical necessity. My question is which doctor writes this letter? Does the letter come from my lap band surgeon or do I have to have my PCP write it. If it has to be a doctor other then the surgeon would I be able to have my gynecologist, who has worked with me on my weight for years write it instead of PCP? Any info anyone can give me would be really appreciated! Thanks!

ReneBean · April 2, 2007

Now that you know there is no exclusion on your policy - it is time to talk to a surgeon. The surgeon's office will know all the "stuff" that you need to get. The insurance company makes the determination as to whether bariatric surgery is "medically necessary" and therefore covered by your policy.

In order to get them to make that determination, you need a letter from your PCP and several pre-op tests packaged and forwarded to them.

See your surgeon - or whoever helps him get his patients approved by Insurance. They will guide you on your way.

Good Luck!!!

losin'it · April 10, 2007

Thanks~

I do have an appointment with a surgeon on April 18th. Was just hoping that I could get as much done and out of the way as possible ahead of time and since it sometimes takes a while to get an appointment with one of my doctors I thought if I knew which one needed to write the letter of medical necessity I could set up an appointment now for shortly after my consultation. I guess I'll just wait until I see my surgeon and go from there.

faithmd · April 10, 2007

I'd set up the appointment for right after you see the surgeon (not the same day, though-surgeons are notorious for running VERY late), you can always cancel it if you don't need to see your PCP. That way you have an appointment.

You can also call the surgeon's office and ask for a packet to be mailed to you with info about what that office requires pre-op. Some surgeons require a psych evaluation, some require sleep-testing, depending on your age or history, others require a scope or an upper GI, it all depends. But if you call now and ask what EVERYONE who is banded by them is required to do, you'll have an idea of what you can get started on. Let them know you are aware that everyone is different and you may require more testing, but you just want to know what you have to do at a minimum. Call your insurance company and ask the insurance company what the requirements are. Most require a letter of medical necessity, and a psych eval or something like that. Have them mail you their policy statement about adjustable gastric banding, that way you have it in writing. You also want something in writing that says what they require to be in that "Letter of Medical Necessity." They may want diet history, or they may not care about it. They may want co-morbidities and may need a BMI in it, they may want something that states you've been X # of lbs overweight for X # of years, etc. That way you know exaclty what they're looking for and can give that info to your PCP to assist in writing the letter.

Good luck!

NVgirl · April 10, 2007

That letter had to come from my primary care physician. I made an appointment with her the week before I initially met with my surgeon to explain what I was doing. She sent that letter and 5 years of medical records to my surgeon.