Experience with letter of medical necessity?

[LizzLosingIt 49]

Hello everyone and welcome to my very first post!

(READ ON TO LEARN A BIT ABOUT ME OR SKIP TO LAST PARAGRAPH IF THIS IS TOO LONG, which admittedly, it probably is lol. 🙂 )

I've been a reader for about a year now, and now that I'm seeing a light at the end of the bariatric tunnel, I decided to join the forum.

I've been wanting to do surgery for a long long time, over a decade at this point. In my early twenties my parents even considered sending me to the Dominican Republic (my birth place) to be with family and get the surgery there with a known doctor. Ultimately the cost was prohibitive for a young girl in college and I was still attempting to lose weight on my own.

Now, my new job has (thankfully) doubled my previous salary AND has a great insurance that actually provides WLS to qualifying patients. I have Cigna and I know their requirements have recently changed, around summer 2020. I'm no longer required to partake in a 6-month monitored weightless plan. All I need are the following:

- Psych eval (took April 27th and was recommended for surgery)

- Blood work (took April 28th, everything came back normal, which always shocks doctors since I'm 300 lbs. creeping toward pre-diabetes but not there yet.

- EKG (came back normal, also taken April 27th, no issues there)

- Gallbladder ultrasound (recommended by my surgeon, taken same day, they said possible sludge but no stones. Kidney and liver looked normal, no lesions.)

- Nutrition consultation (just one, already had it April 28th)

- Letter of necessity from another physician.

Herein lies my biggest issue. My consult was April 21st and all of my appointments were done a week later. Everything is working out so smoothly that it's scary. BUT my PCP recently switched offices so I don't really have one, and with COVID, I saw specialists if I had an issue or a yearly exam and not a general MD. I have sleep apnea and see a neurologist who treats me for it. My surgeon's office said that since I have PPO insurance, the letter can come from my specialist, doesn't have to be a PCP or general practitioner. I called her office to see if she' be willing to hear me out or if I'd have to go in for an appointment. She wants to see me and I understand she wants to be paid for her time. But when I asked the receptionist how she took it, when I asked if she'd be willing to write me my letter of necessity, the receptionist said "do you want the truth?" (of course I do, or I wouldn't have asked.) "she seems... iffy... but... but... just, just come in and we'll see." I'm seeing her on Monday. I'm so nervous that she will say no. My cousin's a doctor and she gave me some great tips on how to ask (which I'll gladly share if you want me to) but I'm so concerned that she'll require a monitored diet plan or she will straight up refuse to write the letter. Has anyone gone through this? What are some ways you spoke to your doctor, and did you get any push-back? I feel like doctors insist on weight loss but look down on WLS. Such a stigma. Any tips are appreciated!

[mswillis5 127]

Congratulations that you are in the final steps that your plan requires. I am going to attach a sample letter that my Surgeon gave me. My PCP followed this letter loosely but if you just have the doctor state some of this information and the comorbidities that they know you have and are treating, that should be all that the insurance is looking for.

From my experience, if you have a good rapport with this doctor then they may be more willing to help with this letter. For my diet summary that I had to give to my insurance, I used my Allergist. She was certified in Obesity though as one of her additional certifications and had referred me to a dietician for help at that time. I also had 6 monthly visits with her when I was on a diet and so all of my weight loss at the time was documented with her.

Good luck with this letter and everything will work out the way that it is supposed to.

PCPLetter.pdf

Edited May 2, 2021 by mswillis5

[lizonaplane 1,612]

Can you go back to your PCP who switched offices even if it's a bit of a drive? Or even ask if the PCP will write you one based on your history as their patient? Or find a new PCP? My PCP is the one who recommended WLS to me.

[LizzLosingIt 49]

Update! I was worried for nothing! I had my appointment with my neurologist today, and we spoke about my normal check up stuff, and barely got the request for the letter fully out of my mouth before she turned her chair around and started typing it up!

now I just need my nutrition evaluation (next Monday) and we can submit to the insurance. So excited and grateful that everything is going so smoothly. Thank you both!

[ShoppGirl 4,786]

Glad it worked out for you.

Edited May 4, 2021 by ShoppGirl