PCP Letter?

Bxample-letter of M edical Necessitv

Re! Name;

Address! City/state/zip:

SS# DOB:

Cerritkate/ 1D#:

slzrgical management of morbid obesity, precisely the Roux en Y Gastrio Bypass procedure.

Sho is a 49 yeat-old woman wNo has a long history of morbid obessq'. She t1y is rnorbidly cbesc

(ICD-9 278.01) With a weight of pottnds and a Body Mass fncl (B5t() Of , Ms.

weighf loss strategits. multiple diet.s and exereise programs (iqcluding a doctor pervjsed low-calorie dieq

dtactor supervised use of flle dfug M erjdian lvctlz a low-calerie cliet, W eight W a hers, Jeaay Craig, low-fat

M s. . ttl orb' ' a g qit

using CPAPI, bigh blood preésure, ohronic lower back paitl. osteoartlultis ln r knees and artkles, stress

jnctmtiaence, depression (th&t i,s exasperated by he..r obesity), slmrtnrss uf br th with exertion, astkma,

gastzo esophageal reflux disease IGERDI a11 which I beiieve will be relieved or ignificantly improved with

surgical management of her obeskty.

A disoussion wts helll wlth the patie'nt describing tho procedtu'e, includin inclk tioasv complications, ! risks

and bellefits, Tllis surgery is nece-ssary to reduce wright and thereby, achlcve i rovement or resolution of

BMl grtmter ttmt 40 kg/m2 (100 lbs, Above ideal body weight). Tlmse gutdeline are in uccordance with the

reçommendations of the NIEI Consensus Development Coaference Statement . d Clinical Guidelines, t.he

American Obesity Association/ Shape-up Amerka; the American Heut Associ ion, and the W orld Hzaltll

Based on ttm degtee of obesity and the mssociated conditioas described above, fed that this patient is an

appropriate carldidate for ttle sroegical procedure, Rou en y (Jastric Bypass f r slzrgical management of

(Physician's Name and Signatlzre) l

D ate

9

SAM PLE LETTER OF M EDICAL CLEARANCE AND M EDICAL NECESSITY

(This should be on the phpicianrs letterhead)

D ate:

Rç: Jane D oe

Patient's DOB.'

Jallö Doe has been a patient since January 1999

obese arld has a BIVII of >58. She has tried several diet prog

which she could not tolerate.

Patient has several co-m orbid conditions which she has suffercd

for the past yeazs. Patient curzently takes m edications A

P

atient is aczve artd has been working as a XYZ but is unable to

reach her full potential due to her m orbid obesity

In my opinion patient would greatly benefit from weight reduction

surgery in addition to preventing secondary complications which

m ay arise i.rl the fllttwe due to hez weight. Pt

cleared for bariatric surgery.

N.!D Signature