Medical Necessity Letter

To Whom It May Concern:

I am twenty-four years old. I have struggled with obesity since childhood. Despite repeated diet attempts, both under the care of a physician and through commercial attempts such as Jenny Craig and Weigh****chers, as well as Dr. Phil McGraw’s Weight-Loss Solution, and Dr. Atkins’ low-carbohydrate/high-protein diet, I have been unsuccessful in achieving meaningful weight-loss, as well as maintaining the weight-loss that I did achieve.

I now have type II diabetes, hypertension, hyperparathyroidism, and the most frightening and serious, end-stage renal disease with all the complications that come along with it. Because of the kidney disease, I am on hemodialysis six days a week. I’m a good candidate for a kidney transplant, however, they cannot approve me for the UNOS transplant list until PacifiCare approves me for the vertical sleeve gastrectomy (VSG) surgery; I say the VSG specifically because it is the most restrictive surgery that will also allow for successful absorption of antirejection medications after transplant. The lap-band would interfere with transplant because of the port in the abdominal cavity, and the roux-en Y and the duodenal switch surgeries rely more on malabsorption than restriction, and as such, any drugs such as the antirejection medication needed for an organ transplant would not be absorbed the way they need to be.

The sooner that you approve me for the surgery, the sooner I can be added to the UNOS list.  I understand that PacifiCare has an arbitrary six-month program requirement that is “mandatory.” I am requesting that this requirement be waived. I have a team of doctors, nurses, and dieticians, as well as social-workers and a therapist (LCSW/MFT) who monitor me and assist me with all my medical needs. Secondly, I was informed that this program is all “telephonic,” and I wonder how exactly a six-month program with people I never meet is going to help me? These people do not know me, do not know my body, do not know my medical situation, and do not know all the limitations and special requirements that the renal failure dictates. A regular dietician does not understand the special dietary limitations for a renal-patient. A non-dialysis nurse doesn’t understand all the intricacies of what I go through on a daily basis. And as for a personal trainer, how exactly does one do personal training over the phone?

I have discussed all these dietary concerns with my dietician and we have made it a point to keep each other updated on what my dietary needs and concerns are currently and what they will be when I have the gastric reduction surgery (VSG).

Now to discuss the cost: by allowing me to have the VSG now, as opposed to six to eight months in the future, there are savings that will come along with it.

            1a) Medication costs: By allowing me to have the VSG as soon as possible, the weight loss will likely allow me to eradicate several medications from my daily health routine, passing the savings along to PacifCare.  Currently, PacifiCare pays for approximately $1,623.35 in medications every month. That comes to a yearly cost of $19,480.20.  This is more than the standard out of pocket cost for the VSG, which ranges from $9,000 to $11,000.

            1b) One of the medications which PacifiCare covers is Fosrenol. This is a monthly cost of $1,115.19 or a yearly cost of $13,382.28.  By reducing the capacity of my stomach through the VSG, I will need less of this medication. The savings on this medication alone could be exceptional.

            2) Hemodialysis costs: by allowing me to have the VSG as soon as possible, it will allow me to be listed with the UNOS transplant list. While I have a common blood-type, there’s always the possibility that I will get a perfect match kidney within a year or two, rather than the current wait time of five to seven. That will pass the savings of dialysis treatment on to PacifiCare as well. Yearly costs of in-center dialysis is approximately $66,367 to $83,869. The sooner I am listed with the Stanford Kidney Transplant Center and the UNOS transplant list, the sooner the cost of dialysis will be eradicated from my healthcare costs.

            3) Currently I undergo biweekly psychotherapy treatments stemming from my health issues, as well as from psychological issues from my lifelong battle with my weight. By allowing this surgery to go forward as soon as possible, the psychological issues from the weight, as well as from health issues (which will begin to resolve after the surgery) will become less pressing, and eventually I may be able to end my therapy sessions altogether; if not, then they will become much more infrequent.

Finally, and though this is not a cost/benefit reason, my quality of life will be much better. I will be able to exercise without pain, without getting winded; I will be able to wear clothing that doesn’t end in “X.” I will be able to be more productive.

Please reconsider the six-month provision. This surgery is not just a weight-loss surgery for me. This is a life-saving procedure that is necessary for my treatment of my kidney failure.

Thank you,

Megan C.