Question about PCP letter

My insurance coordinator says that BCBS requires that my PCP letter says that I am surgically sound or medically cleared. My PCP refuses to write these words. She would only supply me with a form letter stating that according to medical guidelines I should proceed with surgery. Has anyone else faced this obstacle? She claims that she has had many patients get approved with this form letter. I am so concerned about this.

Hi Maureen, I have personally never heard of such a thing. You may want to contact BCBS and ask them if such a form letter would be acceptable and sufficient to accomplish what you require. I think if my PCP had refused to write the letter I needed, I would have sought out another PCP. But, that is just me. I wish you luck. Pat

Thanks Pat I do LOVE my PCP and she is 100% for the surgery... she just thinks that the surgeon should be the one to say I am surgically sound..not her. I will call BCBS and find out what they say

I have that insurance and they do require it. What that means is that your PCP should refer you to all testing he/she feels you need. For instance, I had a sleep test, several cardio tests, and a few others. Once those specialists have said everything is ok, your PCP should feel comfortable with writing that. After all, she should know what she wants you to have. Usually, by the time you get to the surgeon, most of your testing is done. It is my understanding that your pcp should order all necessary testing that they would do before any major surgery. Your surgeon may want more, but your pcp should have no problem writing this. She sounds a little strange to me...maybe you should be shopping for another one...almost like she doesn't trust anyone but her opinion. Good luck!!! Oh, and it helped that my cardiologist thought I would benefit from the surgery too, and that he wrote a letter.

Thanks Kathy I guess I may have to shop for a new PCP... SHe did all the tests,, but is being stubborn about the letter. I guess there goes any chance of having surgery by year end

Hi There, There are two different letters that most insurance companies require from the PCP....I think your PCP might be getting them confused...they are the letter of necessity and the medical clearance. The letter of necessity is where your doctor states that she feels the operation is necessary for your condition based on your medical condition...This letter is absolutely VITAL as it is what the insurance company wants your doctor to prove...that the surgery is medically necessary....they won't just give it to you because you meet the criteria...it has to be proven that it is medically necessary with a perponderance of evidence. Since the insurance company sees our PCP is your "overall" doctor and is the person who coordinates your overall care and refers you out to a specialist when necessary. Your PCP is the one who sees you and has a relationship with you. Since she/he knows all your conditions they are the one to explain them and also explain how you would benefit from the surgery. The surgeon can do the same but think about it from the insurance companies perspective...the surgeon does have something to gain from recommending as many patients as possible for the surgery...the PCP is more or less the gate keeper. As far as the medical clearance letter that is required from the insurance company. They require it so that they can be sure you have been evaluated by your PCP and that your PCP feels that you are healthy enough for surgery....and that there is nothing that they have been treating you for or nothing in your past that would be a danger to you during surgery or post-operatively. Again, it's because the PCP has had a relationship with you and has coordinated your past care. Here is the entire verbage for the letter my PCP wrote for my medical clearance letter: "I have performed a physical exam on Mrs. S and find her at very low risk for perioperative complications. She has been medically cleared for surgery. Please contact me with any questions." That's it...that's all that has to be in the medical clearance letter! I wish you best of luck, it can be very confusing weeding through all of the requirements! Chris S

HI! Don't give up. Mine states about the same as Chris's does. It just says.."has had the following tests...cardio, sleep, blood work up, (etc), and she is surgically sound." Meaning, I passed all the tests, so to speak, that he wanted me to have in order for him to feel comfortable with referring me. I know the information that the surgeon's office gave me, and the experience I had, was that it must say surgically cleared or sound, in one form or another, from your PCP. Some people include it with the medical necessity letter, others get a separate letter. My friend (with the same insurance) used two letters, while I used one. Do you have BCBS of GA? Is it an hmo or ppo? What about all of your testing? Have you had anything done? That might take a while. Don't give up. Call your insurance company and talk to them. Get the name of the person you speak to, and ask them about it. Then call back again, and ask someone different. Also, the person working with your surgeons office should be able to tell you exactly what it should say, and they are always right. It is them that sees the approvals and denials everyday, and the reasons. See what they say.. Take care, and keep the faith. Hugs, Kathy

Thanks Chris The "form" letter my PCP used basically states all the tests I have, and my comorbidites.. Then she used two charts ...One was the American Heart Association and one was the American College of Physicians guideline... Based on my test results, the guidelines say no further testing is required prior to surgery. She did sign a form for me earlier.. said something about her supporting me for surgery..or something like that .. Of course it is the only one I did not keep a copy of ! Anway.. Insurance coordinator is going to send this in, and we shall see what happens from there ! My husband's work is self insured..through BCBS of NC. Keep your fingers crossed for me