xpost: need Statement of Medical Necessity for protein & supplements

Hi all--

I have a Health Care Flexible Spending Account (HCFSA) through my job. Usually vitamins & supplements are not reimbursable without proof of medical necessity from a physician's office. My particular account DOES cover many OTC items, just not THESE.

I am in the process of creating a Statement of Medical Necessity that my doc will be able to sign. I'm asking for your input and also a list of items I should be including for reimbursement (vitamins, protein bars & powders etc). I don't want to miss anything, since this one-time letter would be enough to cover my reimbursement for a year.

Basic info that I need to include: patient's name, diagnosed condition and recommended treatment.  I will use the verbiage from my patient education manual for treatment recommendations. (I know my doc's office can do this, but I'd really like to do as much legwork for them as possible. They will change anything they don't want to list.)

My questions for you are:

1. Does anyone have current diagnosis codes available to them? Is there a diagnosis code for having had a lap RNY? I know there is a CPT code, but is there a "post RNY bariatric surgery" diagnosis code?

2.  For which items should I ask for reimbursement? I am drawing a blank beyond the vits & proteins...

Thanks for all of your help. I am willing to share this blanket "fill it in" form with others once I've completed it.

Michele

Hi Michele -

I also have a FSA and use it for my vitamins, protein and other supplements (calcium and such).  My return-to-work form from the surgeon's office had information on it about the need to drink protein supplements and take OTC vitamins, so I used that and it was fine.  I have not had any problems getting reimbursed for multi-vitamins, protein powder or any other supplements I've purchased.  They just keep the note in my file and I don't have to resubmit it everytime. 

My form was very non-specific.  It basically just said I would need protein supplements and various vitamin and mineral replacement supplements.  That pretty much covered everything I'd ever need.  There's no diagnosis code needed.  It did mention that I had RNY/gastric bypass... so I think that covered any questions.

This reminds me that I need to get another reimbursement request together and get it faxed over.  It's a pain, but definitely worth it for the tax savings.  Unfortunately, I think I overestimated the amount I'd use after surgery and might end up scrambling at the end of the year.  I calculated all my co-pays for dr. apts and prescriptions and all my OTC stuff.... but neglected to figure that I would be OFF all my Rx meds within a month after surgery and wouldn't need to pay all those co-pays for drugs. 

Good luck
Pam

Hi Pam-

You just reminded me about changing the $$ I have taken out for NEXT year! I won't need all of the Rx copays either. I don't know how much to estimate for vits & protein for my first postop year. Any ideas?

Michele:

This post might help you come up with a rough estimate
http://pamtremble.blogspot.com/2008/07/price-of-post-op-life .html

Right after surgery I spent more on protein powders than I do now, 9 months out.  I was drinking 3 shakes a day for the first couple months, but not I'm down to just 1 per day.  Also vitamins are tough to estimate because you don't know what your bloodwork is going to show.   Go with the basics of what you think you'll need, then add a small cushion.

It's a total guessing game.  LOL!  Just do the best you can without overshooting by too much -- because what you don't use, you lose.

Pam

Thanks!

This is what I came up with for a SMN:

STATEMENT OF MEDICAL NECESSITY

This statement is to assist the following employee in obtaining reimbursement from his/her

Health Care Flexible Spending Account for items that might otherwise be considered non-reimbursable

 

DATE:

EMPLOYEE NAME:                                               DOB: 

ADDRESS: 

RE:  (patient’s name & DOB)

           

DIAGNOSIS:  Post-surgical malabsorption 579.3

 

To Whom It May Concern:

(PATIENT’S NAME) was seen in my office on (DATE) for (HIS or HER) first postoperative visit following laparoscopic Roux-en-Y gastric bypass on (DATE). (HE or SHE) is recovering nicely.

Because (HIS or HER) operation included bypassing approximately 100cm of the proximal small intestine and creating a small gastric pouch, (HE or SHE) is at an increased risk for deficiency of certain nutrients. Decreased dietary intake in combination with varying degrees of malabsorption presents unique challenges to achieving the macronutrient and micronutrient status needed for (HIM or HER) to thrive.

 

Lifelong preventative actions, such as supplementation, regular physician and nutritionist follow-up, and thorough patient education are mandatory for accomplishing all the benefits and avoidance of the health risks involved in Roux-en-Y gastric bypass surgery. The focus, therefore, is on risk reduction and careful lifelong monitoring and follow-up.

 

 

 

In light of (HIS or HER) malabsorptive state, it will be medically necessary for (HIM or HER) to utilize a variety of vitamins, minerals and nutritional protein supplements for the rest of (HIS or HER) life.

 

 

 

 

 

If you have any further questions, please do not hesitate to contact my office at (PHONE NUMBER).

 

 

 

Sincerely,

 
PHYSICIAN NAME AND TITLE

Name of Practice or HospitalAffiliation
PHYSICIANADDRESS
CITY, STATE    ZIP CODE

Michele -

LOL!  This is WAY too much information.  They really do not need this much and you don't need to provide this much detail about your medical records.  Have you called the surgeon's office to see if they already have something that'll work?

The form I faxed serious just had this:

_________ blank line where my name was handwritten
_________ today's date

Bullet points:

* patient must be allowed to drink water at his/her workspace
* patient has malabsorption syndrome and must follow vitamin and mineral supplement guidelines
* patient must supplement diet with  low calorie protein supplement

(a few other bullet points related to returning to work with specific restrictions)

The statement does not need to be specifically addressed to the FSA account people or even relate to their policies.  It doesn't even need to be a prescription.  Just a statement from your surgeon's office stating you have malabsoption syndrome or whatever ... that necessitates vitamins, supplements and protein. 

Your surgeon's office probably already has this.  Just ask them.

Pam