Insurance Letter Info Needed!

Hi, My sister is in the process of getting her insurance to pay for lap band surgery. She has gone through all the preliminary appointments and testing (sleep apnea, psychiatric evaluation, PCP appointment, initial consultation with surgeon, etc.) and is now ready to write the letter of medical necessity to her insurance company. While her PCP supports her decision, she was told that she would need to craft and submit the letter herself. Do any of you have examples of the letters you wrote to your insurance company to start the approval process that you could share? I was self pay for my band surgery on 10/14/05, but I'm trying to help guide her through the process of becoming a bandster. Any advice you can provide would be extremely helpful. Thank you! Monica Banded 10/14/05 -60 lbs. so far!

Sorry to respond so late. I don't check this board often, but there is a book called WLS for dummies that has a sample insurance letter in. Hope that at least gets you started.

Here is a letter I wrote listing all my co-morbidities. I haven't heard back yet so not sure if this will work. I think the key is to list all your co-morbidities & make them sound as potentially life-threatening as possible. Good luck! Dear Sir or Madam: I am writing to request approval for Laparascopic Gastric Banding surgery. I am 5 feet 2 inches tall and weigh 221 pounds. My current body mass index is 38.5. The degree of obesity associated with my BMI is morbid. At my highest weight of 232 pounds, my BMI was 43. I am having significant adverse symptoms from my obesity including: Hypertension. I have a history of hypertension dating back 25 years. Hypertension is a key factor in vascular disease leading to stroke, heart attack, as well as kidney function. Hypertension also accelerates the loss of kidney function in people with all types of kidney disease. Interventions have been successful at reducing the risk of hypertensive stroke and myocardial infarction, but renal failure from hypertension has not declined. About 25 per cent of people treated for kidney failure in the United States have lost kidney function because of hypertension, a disease on the rise (http://www.niddk.nih.gov/fund/reports/wholeRDRC.pdf). In many cases, the weight loss attained by lapband surgery has been shown to cure hypertension. Progressive chronic Kidney Disease. I was diagnosed with Bifocal Glomerulosclerosis approximately 10 years ago. This progressive kidney disease is particularly troublesome in my case since both my kidneys are deteriorating at the same rate. Treatment for Glomerulosclerosis focuses on controlling the symptoms, minimizing complications, and slowing the progression of the disease. Unlike acute renal failure with its sudden, reversible failure of kidney function, chronic renal failure slowly gets worse and can range from mild dysfunction to severe kidney failure. Progression may continue to end-stage renal disease (ESRD) (http://www.nlm.nih.gov/medlineplus/ency/article/000471.htm). Dialysis or kidney transplant may be required eventually. Hypertension, or high blood pressure, is the second leading cause of kidney failure (http://www.niddk.nih.gov/fund/reports/wholeRDRC.pdf). Gastroesophageal reflux disease (GERD). Obesity is a major contributing factor to GERD. I have regular episodes of acid reflux and have had only some relief from Zanta****ep bottles of Tums in my night table, my kitchen, my desk at work and my car. Sometimes GERD can cause serious complications. Inflammation of the esophagus from stomach acid causes bleeding or ulcers. In addition, scars from tissue damage can narrow the esophagus and make swallowing difficult. Some people develop Barrett's esophagus, where cells in the esophageal lining take on an abnormal shape and color, which over time can lead to cancer (http://digestive.niddk.nih.gov/ddiseases/pubs/gerd/). Barrett's esophagus is estimated to affect about 700,000 adults in the United States (http://digestive.niddk.nih.gov/ddiseases/pubs/barretts/index.htm). Urinary stress incontinence. Although I take prescription drugs to help with this, I need to wear protective pads at all times. A large heavy abdomen and relaxation of the pelvic muscles may cause the valve on the urinary bladder to be weakened, leading to leakage of urine when coughing, sneezing or laughing. This condition is strongly associated with being overweight and my doctor believes this will be relieved by weight loss. Infertility. I have been unable to conceive. My husband and I have both undergone fertility testing which have shown no physiological reasons for our infertility. My doctor believes that our infertility may be related to my obesity. Obesity has been shown to contribute to reproductive problems in women, including menstrual irregularities and infertility (http://win.niddk.nih.gov/publications/PDFs/adultobesbw1201.pdf). Depression. I suffer from depression and tend to avoid social situations. Seriously overweight people face constant challenges to their emotions, repeated failure with dieting, disapproval from family or friends, sneers and remarks from strangers. Emotional suffering may be one of the most painful parts of obesity. American society emphasizes physical appearance and often equates attractiveness with slimness, especially for women. Such messages make overweight people feel unattractive. Many people think that obese individuals are gluttonous, lazy, or both, even though this is not true. As a result, obese people often face prejudice or discrimination in the job market, at school, and in social situations. Feelings of rejection, shame, or depression are common (http://win.niddk.nih.gov/publications/PDFs/adultobesbw1201.pdf). Skin rashes. I have persistent rashes in the folds of my body due to my obesity. Obesity creates these folds so that skin rubs on skin and the moisture trapped in those creases causes infections and rashes. I have used over-the-counter remedies to no avail. Waste circumference. Excess abdominal fat is an important, independent risk factor for disease. The evaluation of waist circumference to assess the risks associated with obesity or overweight is supported by research. The measurement of waist-to-hip ratio provides no advantage over waist circumference alone. Waist circumference measurement is particularly useful in patients who are categorized as normal or overweight. Men who have waist circumferences greater than 40 inches, and women who have waist circumferences greater than 35 inches (mine is 45), are at higher risk of diabetes, dyslipidemia, hypertension, and cardiovascular disease because of excess abdominal fat. Individuals with waist circumferences greater than these values should be considered one risk category above that defined by their BMI (http://www.nhlbi.nih.gov/guidelines/obesity/prctgd_c.pdf). Diabetes. Although I am not currently diabetic, there is a history of diabetes in my extended family including my uncle *****cently died of diabetic complications at the age of 59. My obesity places me at greater risk for adult-onset obesity; as nearly 80% of patients with this disease are obese. Obesity is more than a cosmetic problem; it is a health hazard. Approximately 280,000 adult deaths in the United States each year are related to obesity. Several serious medical conditions have been linked to obesity, including type 2 diabetes, heart disease, high blood pressure, and stroke. Obesity is also linked to higher rates of certain types of cancer. Obese men are more likely than non-obese men to die from cancer of the colon, rectum, or prostate. Obese women are more likely than non-obese women to die from cancer of the gallbladder, breast, uterus, cervix, or ovaries (http://win.niddk.nih.gov/publications/PDFs/adultobesbw1201.pdf). I have made many attempts at losing weight over the past 15-20 years including eDiets (see attachment), Weigh****chers (see attachment), Jenny Craig, Nutrisystem, Herbalife, nutritional consultations, gym memberships, and other over the counter diet plans. I have included exercise with all weight loss attempts and have been able to lose some weight, but gain it all back and more. There are no studies that conclusively show that dieting brings permanent weight loss. The National Institutes of Health, in 1991 and 1992 consensus statements rebutted conventional diets for morbid obesity and pointed to this important fact: diets alone cannot be successful for the morbidly obese. 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 Permanente Medical care Program were studied to determine the association between body fatness and health care costs. The results showed that patients with a BMI greater than 30 had a 2.4 times greater risk for increased inpatient and outpatient costs than patients with BMI's under 30. For patients with BMI's greater than 30, the study also showed increases in health care costs related to diabetes and hypertension. Given my over the long-term life-threatening co-morbidities and other adverse symptoms of obesity described above, I respectfully ask that you approve my application for Laparascopic Gastric Banding surgery. Thank you very much for your consideration. Sincerely,