Need sample Letter from PCP

I know I have found sample letters and what information should be included. Now when I need the list of items, I can't locate information Please help with list of areas the letter should cover. PCP to insurance company and or surgeon. Thanks bunches. Marla

Marla, I found this one on another site... Sample of My Letter of Necessity Date Insurance Company Address City, State, Zip RE: Your name Group #/Plan # Member ID # Request for Pre-approval for gastric bypass surgery (CPT-4 Code= 43847) To Whom It May Concern: Mr./Ms. ______ has been under my care/associates for the past ____ (__) years. He/She is ___ years of age, stands ___" tall and weighs ___ lbs. He/She has a history of childhood and adult obesity with a current BMI of ____. The body mass index is calculated by dividing a person's weight in kilograms by their height in meters squared. When a man's BMI is over 27.8, or woman's exceeds 27.3, that person is considered obese. The degree of obesity associated with a particular BMI ranges from mild obesity at a BMI near 27, moderate obesity at a BMI between 27 - 30, severe obesity at 30 - 35, to morbidly obese for patients with a BMI of 40 or greater 1,2,3. Mr./Ms. ______ weight condition has caused him/her significant health problems, some of which appear to be getting progressively worse as time goes on. Some of this patient's current health problems are lupus, painful gallstones, leg, ankle and foot pain, varicose veins, and edema. Mr./Ms. ______ knows the health risk associated with morbid obesity and has done his/her best at attempts to control his/her weight. In an effort to resolve his/her weight problem, he/she has undergone numerous weight loss treatment plans such as: Weigh****chers Diet - 1992 for 6 months (starting at ___ lbs. - ending at ___ lbs.) American Heart Association Diet - 1993 for 1 month (starting at ___ lbs. - ending at ___ lbs.) Slim Fast Diet - 1993 for 3 months (starting at ___ lbs. - ending at ___ lbs.) Liquid Protein Diet - 1994 for 3½ months (starting at ___ lbs. - ending at ___ lbs.) Weigh****chers Diet (2nd time) - 1996 for 6 months (starting at ___ lbs. - ending at ___ lbs.) Phen-fen in combination with Pondimin Diet Pills - 1997 for 3 months (starting at ___ lbs. - ending at ___ lbs.) Mr./Ms. ______ has been under my care for the past four years and within that time I have monitored his/her success/failure on numerous weight loss programs. Mr./Ms. ______ first weigh in at my office was at ___ lbs. and his/her weight today is ___ lbs. His/Her highest weight under my supervision was ___ lbs. and the lowest was ___ lbs. The programs that I have personally monitored are as follows with exercise: Dr. Adkins Diet - 1998 for 3 months (starting at ___ lbs. - ending at ___ lbs) The Rice Diet - 1998 for 3 weeks (starting at ___ lbs. and ending at ___ lbs.) The Cabbage Diet - 1998 for 2 weeks (starting at ___ lbs. - ending at ___ lbs.) Dr. Adkins Diet - 1998 for 3½ months (starting at ____ lbs. - ending at ____ lbs.) MOST RECENT ATTEMPT AT WEIGHT LOSS - Lean Bodies (low fat, carbohydrate and sodium diet) in combination with Xenadrine RFA-1 over the counter diet pills, along with a gym membership at LA Fitness - 2001 - 2002 for the past 17 months and still currently attempting (without Xenadrine RFA-1 since 8/2002 makes him/her extremely anxious and nauseous. Since Mr./Mrs. _______ stopped taking Xenadrine RFA-1 he/she has re-gained ___ lbs. of his/her ___ lbs. loss. Please see month-to-month details below: MONTH WEIGHT LOSS GAIN NOTES 01/2001 270 02/2001 264 6 03/2001 259 5 04/2001 255 4 05/2001 251 4 06/2001 244 7 07/2001 240 4 08/2001 233 7 **Discontinued Diet Pills 09/2001 230 3 10/2001 237 7 11/2001 242 5 12/2001 248 6 01/2002 255 7 02/2002 257 2 03/2002 251 6 04/2002 252 1 __ lbs. is the most weight loss Mr./Mrs. ______ has ever had at one time in the past 10 years. That was done through diet pills, change of eating habits (dieting) and exercise. As you can see, it has had no long-term success. It is my recommendation that Mr./Mrs. ______ not continue taking diet pills, especially while taking medication for his/her lupus. I feel the side effects could be more damaging to his/her and only cause additional health concerns in the future. Mr./Mrs. ______ has been over ___ lbs. For the past 10 years and up until 2 years ago has been extremely lucky not to of have any major health concerns. Mr./Mrs. ______ attempt at losing and re-gaining weight has only proven to cause his/her more health concerns. Mr. /Mrs. is a very active male/female. His/Her work profession _______ which demands extreme physical activity and as long as I have known him he has participated in many recreational activities such as___________ . It is time for a PERMNANENT resolution to eliminate future health concerns related to morbid obesity. For the past two years Mr./Mrs. ______ has been on predisone (steroids) under Dr. ______ care for treatment of his/her lupus illness, which in itself causes weight gain. From the success rate known from gastric bypass surgery and health benefits involved, I feel this would be the BEST solution for PERMENANT weight loss and beneficial for future health concerns due to morbid obesity and current health conditions from worsening. Obesity has been shown to directly increase health care costs. In an article in the March 9, 1998, issue of the Archives of Internal Medicine 17,118 members of the Kaiser Permenente Medical Care Program were studied to determine the association between body fatness and health care costs. The results showed that patients with BMI's greater than 30 had a 2.4 times greater risk for increased inpatient and outpatient costs than patients with BMI's under 30. Americans spend an additional $33 billion dollars annually on weight-reduction products and services, including diet foods, products, and programs. Most of these expenditures, as is evidenced in this case, are not effective. Rather it can expected that he will continue to gain weight and the costs of co-morbid conditions, including the ones he already has and ones he surely will acquire as time goes on, will far outweigh the costs of gastric bypass surgery that we are asking you to please approve for this gentleman/lady. I trust this information will aide you in understanding the true severity of Mr./Mrs. ______ 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, Your Doctor's Name Hope this Helps! Erika L

Thanks, I knew there was one some place. I have been to so many sites doing research, the name had left me. I will learn to bookmark things I may need at some future time. Marla

Erika, Great sample, I wrote mine with help from others but this one covers it all. Marla, this a great starting point, then make it yours. Everyone on this site is so helpful. You all share your information freely. THANK YOU!

The sample PCP letter is fantastic and I can certainly amend it to fit my situation, but my question is since I have new insurance I now have a new doctor that I've never had before and therefore have no history with her. Do you think that will make a difference to the insurance company?

Did you have your medical records transferred from your old doctor to the new one? If so, perhaps she can review your records and use that information. If you did not, could you ask your old doctor to write your letter and the new doctor cover period she has been seeing you? You need to have medical records sent to your new doctor. The records are yours. Good luck! Marla