Need help with my "pre-determination" letter

Of course, I was informed by my insurance that bariatric surgery is an exclusion on my policy and in order for it to even be considered my PCP (primary care physician) must write a letter for "pre-determination".  I assume the letter will mention that it is for preoperative, surgical and post-operative care and service.  Does it have to mention the surgeon's name that I have selected, becuase I am currently undecided at this moment.  Does the letter have to indicate my BMI?  Does the letter have to specify which type of surgery I have selected?  I am undecided with that as well, but am leaning towards the Lap-Band.  I also assume the letter must explain my medical history, such as:  acid reflux disease (or GERD), stomach ulcer, and high blood pressure, urologic problems, gallbladder needs to be removed, previously consulted and treated by an endocrinologist, depression and sleep apnea.  I am positive that medical records must be attached to support all those health concerns and risks.  Should my letter mention that I have been battling weight gain issues since 1999 and that it is a major impact on my life?  Does the letter have to state that the endocrinologist and my PCP both put me on 2 different RXs of diet pills with very little weight lost?  Does the letter have to state I have tried several diets and exercises with no success?  Does this letter have to state that it is medically necessary for me to have this surgery?  I can probably get my doctor to state that he strongly believes that surgery would be beneficial to me in regards to helping me accomplish weight loss and at the same time alleviate all symptoms and/or health issues affiliated with weight gain. I want to make sure my letter is done right and done right the first time.  I want to know what to say to convince the insurance company that I need this surgery and to approve it. I need help and suggestions for me to pass on to my PCP.  Please let me know.  THANKS. Take care and be safe. Joiousone

May I ask what insurance you have...... because as far as I know- an exclusions is an exclusion. I am apealing my exclusion. I was told i had coverage but was told after all my testing its an exclusion and what i thought was approval for my surgery was pre-determination. you need to contact them again and find out if there is any chance fo an approval even with WLS being excuded on your policy. good luck to you.

First, let me sat THANKS so much for your response, as I appreciate it.  My insurance is UHC (United HealthCare).  I spoke to UHC and they stated it is an exclusion on my policy, and I asked how I could go about getting it covered.  They replied that I would have to have my PCP write a predetermination letter and then their medical review team will go over everything submitted and reply with their decision if they deside to cover it or not.  I have actually been in the medical field for 18 years myself and the last 9 years I have been doing medical billing, as I am a "Medical Insurance Specialist".  I do know some in and outs about it, but not everything.  Good luck with your appeal.  What exactly are you doing to appeal it?  THANKS again.  Best of luck to you.

It depends on where the exclusion lies; generally, it's because your employer decided not to put it in the policy or pay for it, and you'll have to battle with your HR, not the insurance itself. That being said: -You should definitely mention medical issues related to the obesity, as well as others that can be assisted by the weight loss (eg. joint pain, HTN, etc.) -You need to include chart notes that show your weight loss attempts and weight changes. -You will need to include a current BMI -You will need to include the type of surgery you have chosen, or if you're torn between 2, put them both in (I chose the VSG, just for reference). -include family history -include reccommendations from both the PCP and the endo. that this is a medically necessary surgery. Send one copy to the insurance company, and one to HR. Generally even if the insurance covers it, the exclusion is on the employers' side, and that's where your fight is going to be.

First, let me sat THANKS so much for your response, as I appreciate it.   My insurance is UHC (United HealthCare).  Actually, I have COBRA (continuation of my insurance from my last employer, even though I no longer work there).  The job I am at now does not offer health insurance.  My insurance runs out Feb. 2008, so I am trying to get this all taken care of before then.  I am not exactly sure where in the contract the exclusion lies, as I was not informed that information.  I personally spoke to UHC and they stated it is an exclusion on my policy, and I asked how I could go about getting it covered.  They replied that I would have to have my PCP write a predetermination letter and then their medical review team will go over everything submitted and reply with their decision if they deside to cover it or not.  I was informed by UHC to take it up with them, not my old employer HR department.  I appreciate your suggestions and advice, but I find that a bit odd and out of the ordinary, as I do not think that they have control over what my insurance would cover or not cover, even though the insurance policy is through them.  That is all new to me.  I never heard that before.  WOW!  This is the whole reason behind the forum.  THANKS.  I have actually been in the medical field for 18 years myself and the last 9 years I have been doing medical billing, as I am a "Medical Insurance Specialist".  I do know some in and outs about it, but not everything.   I do have several health issues related to my weight gain that will definitely be mentioned in the letter and supported by documentation (medical records).  I have High Blood Pressure, Acid Reflux Disease (GERD), Urology problems, sleep apnea, thyroid issues, depression and others.  I have not really had any joint pain.  I have no record of that and can not prove that. I have made several attempts to lose weight in the last 7 years.  i never kept any record of them and I definitely do not remember them all.  I have a recent chart and record, as I have been recording myself my work out exercise history for the last 15 weeks.  However, I have never made any attempt to record what I eat.  My PCP did recommend me to go to a Nutricianist, but I was unable to do so, as that was an an exclusion as well and required a predetermination letter.  I was told if it was covered a $500 deductible would apply.  I pay $415 a month for the insurance.  I can not possibly do $415 and %500 all in one month.  I live alone.  I was eager to see how a nutritionist could help me.  My doctors notes and etc. show my weight changes, as they weight me every time I go to the office.   The only BMI I know is the one mentioned on here, based on my height and weight along with my health problems and issues.  Will that be sufficient?  I have never had a real BMI measurement done professionally.  I probably wont get that until I see the surgeon, which I need the predetermination letter prior to seeing the surgeon.  I would like to consult the surgeon first before I put that in the letter. I am undecided as to what type of surgery to select and what would be best for me.  I would like to discuss that with the surgeon.  Again, this predetermination letter is for me to see a surgeon and will be prior to me seeing the surgeon.  I am kind of leaning towards the Lap-Band, but am not sure if that is the right choice for me.  Again, I would like to consult the surgeon first before I put that in the letter.   I had no idea that my family history was required.  WOW!  THANKS for the heads up on that one.  That was helpful.   My PCP will be the one writing the letter and recommending it, I will just ask him to make sure he states it is medically necessary.  I have not seen the endocrinologist in quite some time, but I do have medical records from her to submit with the letter. The predetermination letter is going to be like 3 pages long with all this information.   THANKS sweetie, for all your help, advice, and most importantly your suggestions.  I appreciate it so very much. Best of luck to you.  Keep me posted and stay in touch, if you would like to do so.

I too have UHC and mine is an exclusion by my employer.  I was never told about letter of predeterminaion. Unfortunately i was told due to several errors n UHC part i ad coverage and needed a letter of medical neccissity rom my PCP and my surgeon. Now, after the fact they are reversing what was told to me ws not coverage and medical necissity but a letter of pre-determinaton. so now i need to appeal. without aproval i cant afford this on my own. hopefuly for you it will work since UHC has already given you correct inormation. keep in ouch and let me know what happens with your case.

I appreciate your response.  THANKS.  I have been having some problems with my home computer and that is why I have not been able to reply to you sooner.  SORRY! HHHMMMMMM.  An exclusion by your employer.  Well, that will not look good for me, as I have COBRA (continuation of health insurance) from my OLD employer.  I do not work for the people any more that I currently have my insurance through.  Therefore, that means if my OLD employer has any input, I am sure it will be negative.  However, UHC told me that they have a their own review team that will review it and get back to my PCP with their final decision.  I wonder if they call my employer.  I hope not.  When I called UHC and inquired about this, I was not told anything about my employer.  Are you going to try a letter of predetermination?  My next move is to contact my physicians such as my urologist (urology problems), endocrinologist (weight anf thyroid issues), nuerologist (sleep apnea) and my gastro (acid reflux dicease) doctors and ask them all to write a letter of medically necessity for me.  I have asked my mom to put in writing for me all the medical history of her and my dad along with both their parents.  I am going to do all I can to get this covered.  I want to have all the information I need before I submit the letter.  It all boils down to documentation!!!  I can not see a surgeon without a predetermination letter done first.  My PCP wrote me a predetermination letter to see a nutritionist, as that too is not covered.  I have not yet gotten the results from that.  My PCP is very good to me and generally does whatever I ask of him or his office.  I have been his patient since 1999 or earlier.  He is 45 minutes from me, but I will not change, becuase he is a great doctor and that is hard to find these days.  Anytime you talk to anyone with an insurance company always ask the representative's first name along with the first initial to their last name, note the date and time called and MOST IMPORTANTLY ask for a reference or confirmation number for the phone conversation.  Make notes and keep track of it all.  The funny thing with UHC is that they told me that a nutritionist and bariatric surgery are exclusions on my policy and both require letters of predetermination to even be considered and the review department will go over everything and reply with their decision.  However, my nutrtionist called and verified my benefits and was told it was covered with a $500 deductible, and that other than that I had no responsibilities, such as copay or coinsurance.  I have no idea which of the two is correct.  I am nto chancing it.  No one knows how to do their job any more.  This whole thing can be very frustrating.  Girl, I hear you loud and clear.  I too could NEVER afford this on my own.  I live on my own and I pay my own bills.  I basically live paycheck to paycheck.  I need this to be covered by my insurance.  Since we have the same insurance, I will keep you posted and updated with whatever I find out.  Who knows, we may be able to help each other.  I write letters of appeal on a regular basis as my job requires it.  I do it on behalf of the patient, but to help get the facility payment.  I am a "Medical Insurance Spacialist".  I thank GOD for that, as it may help me with this situation.  Did you read the other person's response to my post?  Read it, it may help.  If there is anything I can do to help, just let me know.  Good luck and please keep in touch and keep me informed of everything going on with you and your situation.  Take care and be safe. 

I have not heard from you.  I hope all is well.  Keep in touch, if you can.  Take care and be safe.

sorry i was at work today. i sent in my appeal letters and am waitng to hear about them. i wil keep you updated.

No need to apologize.  Good luck with your letters of appeal.  Kepp me posted and updated.  Take care and be safe.