Letter of Medical Necessity

Well, I finally wrote my letter. Will you all read over it and see if you see anything wrong or something I should add or leave out? Thanks! LETTER OF MEDICAL NECESSITY Joni L. Branscome Group No. ID# REQUEST FOR PRE-CERTIFICATION FOR GASTRIC BYPASS SURGERY I am writing to request your pre-approval for gastric bypass surgery (Diagnosis Code 278.01 Procedure Code 43847) I am 5 ft. 10 inches tall and I weigh 365 lbs. My BMI (Body Mass Index) is 50.4. When a woman's BMI exceeds 27.3, that person is considered obese. The degree of obesity associated with a particular BMI ranges from mild obesity at a BMI of near 27, moderate obesity at a BMI of between 27-30, severe obesity at 30-45, to very severe obesity for patients with a BMI of 40 or greater. Therefore, I am classified as being very severely obese. The annual number of deaths in America attributable to obesity has been estimated to be 300,000 deaths per year. With my abnormally high BMI, I am at an increased risk of death at my present weight. I ask for your pre-approval for this surgery. I will detail the issues of medical necessity. I am having significant adverse symptoms from my obesity. I have difficulty standing, and in doing any kind of exercise, even walking more than a short distance. I have difficulty performing any daily activities. * I have sleep apnea. Sleep apnea - the stoppage of breathing during sleep - is common in the clinically severely obese. This condition has a high mortality rate and is a life-threatening problem. People are usually permanently cured of sleep apnea with gastric bypass surgery and the permanent weight loss it brings. * I suffer from Fibromyalgia and Osteoarthritis. I must use a walking cane or walker to get around. I am forced to use the electric wheelchairs when shopping. One of the nearly intolerable problems is the constant pain of the weight-bearing joints. An increase in body weight adds trauma to weight bearing joints and excess body weight is a major cause of osteoarthritis. This is a mechanical problem and not a metabolic one. The hips, knees, ankles and feet have to bear most of the weight of the body. These joints tend to wear out more quickly, or to develop degenerative arthritis much earlier and more frequently, than in the normal-weighted person. Eventually, joint replacement surgery may be needed to relieve the severe pain. Unfortunately, the obese person faces a disadvantage there too - joint replacement has much poorer results in the obese. Most orthopedic surgeons refuse to perform the surgery in severely obese patients. The permanent weight loss of gastric bypass surgery will markedly decrease problems with arthritis and the ever-increasing expenses to the insurance companies that will surely follow. * I have hypercholesterolemia (high cholesterol). Where there is too much cholesterol in your blood, the excess can become trapped in the walls of your arteries. By building up there, the cholesterol helps to cause hardening of the arteries or atherosclerosis. And atherosclerosis causes most heart attacks. How? The cholesterol buildup narrows the arteries that supply blood to the heart, slowing or even blocking the flow of blood to the heart. So, the heart gets less oxygen than it needs. This weakens the heart muscle, and chest pain (angina) may occur. If a blood clot forms in the narrowed artery, a heart attack (myocardial infarction) or even death can result. * I suffer from stress incontinence. 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. This condition is strongly associated with being overweight, and is usually relieved by weight loss. * Because of my weight, I am depressed. Seriously overweight persons face constant challenges to their emotions: repeated failure with dieting, disapproval from family and friends, sneers and remarks from strangers. They often experience discrimination at work, and cannot enjoy theatre seats, or a ride in a bus or airplane. There is no wonder, that anxiety and depression might accompany years of suffering from the effects of a genetic condition - one which thin people all believe should be controlled easily by will power. I suffer from depression related to obesity and see a psychologist every two weeks and have taken most every antidepressant on the market in attempts to treat it. * I become short of breath on any exertion. I cannot climb even one flight of stairs without stopping and have a very difficult time performing the day-to-day duties of living, such as shopping, cleaning, getting in and out of cars or chairs. I was once physically active, was active in ballroom dancing, walking, swimming, gardening, but at this time, I find that I am unable to perform any recreational activity, and feel depressed because I cannot control or lose the weight. Walking short distances causes the obese to become very short of breath. Obese persons find that exercise causes them to become out of breath quickly. The lungs are decreased in size, and the chest wall is very heavy and difficult to lift. At the same time, the demand for oxygen is greater, with any physical activity. This condition prevents normal physical activities and exercise, often interferes with daily activities, such as shopping, house cleaning and can be completely disabling. The simple act of taking a shower becomes an overwhelming task. Losing weight will cure these problems. I have made constant attempts to lose weight, beginning when I was six years old. I cannot remember a time when I wasn't dieting, worrying about my weight or trying to exercise to the extreme in attempts to control my weight. I have done every diet that came along, the safe ones and the unsafe ones. I have included exercise with all my weight-loss attempts, even now when it is almost impossible to move my body. I have lost some weight, only to gain it back plus more. There is not one study that shows that dieting brings permanent weight loss. Diets alone cannot be successful for the severely morbidly obese. If they were, I would be thin today. No woman chooses to weigh 365 lbs. I have done everything in my power to stop this horrendous medical problem. I am unable to lose any weight at this point, no matter how little I eat or how much I exercise. Gastric bypass surgery is my only option. I need this surgery to save my life. Obesity has been directly related to increased health care costs. 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 evidenced in my case, are not effective. Rather it can be expected that I will continue to gain weight over the ensuing years and add to this present list of obesity associated illnesses. Weight is an American obsession. Ironically, the more Americans struggle to be thin, the more overweight we become. Seriously obese persons suffer inability to qualify for many types of employment, and a lower socioeconomic status. Ignorant persons often make rude or disparaging comments, and there is a general societal belief that obesity is a consequence of a lack of self-discipline or moral weakness. We are ostracized by society and are often mistreated by the medical community that claims to be helping us. Many severely obese persons find it preferable to avoid social interactions or public places, choosing to limit their own freedom, rather than suffer more embarrassment. I do not want the surgery so I can look great or to make members of my family or the opposite sex happy. I need it for health reasons, as you can see. This surgery is giving people back their lives. Obesity is the third largest killer in the nation. A cure has been found. If you deny this surgery, it would be like not allowing a cancer patient treatment. If you think denying this request would save money, in the long run it would cost much more. Surgeons don't just pick anyone to have this surgery. We go through a whole battery of tests. I have struggled with my weight since I was six years old and have been morbidly obese for over 20 years and my health has deteriorated as a result. I want to be healthy again and I know that this surgery can save my life. I ask that you pre-approve this surgery so that I can become a healthy, productive person once again. Thank you very much for your consideration

The letter looks good -- however, to put the final touches, I would include a list of failed weight loss attempts (i.e., Weigh****chers, Jenny Craig, prescription medications, low fat, low carb, low cal, Body for Life, etc. ([isting for each how much you lost, how long you followed the program, how much you regained, etc.]) Cover ALL the bases with one letter -- leave nothing to chance or question. Just because a diet attempt was not "doctor supervised" does not mean that an insurance company will not consider it (WW for example). I listed my weight loss attempts for the past 10 years - with the ups/downs, etc. Although I do not have Aetna (I have BC/BS) I was approved from the word go (I also had my PCP write a letter of NECESSITY [key word there], the surgeon, and I had a letter from my orthopedic). Best to have all of your doctors supporting you and in your corner! I hope it all turns out well for you. I love you sweets -- keep your chin up!

Great ideas Nil! I used this form, sent to me to fill out, it gives you an idea what the insurances companies are looking for. You can download the same form I had to send in with my stuff here at Dr. B's website. Download it and fill it out, go back as far as you can remember, including diet pills you were on, and include you losses and gains as well as exercise plans you followed or gyms you goined. I included short term sucesses showing I did loose alot once but could never keep it off. I was told it helped them in making their decision. http://www.universityassociatespc.com/usapc/resources.asp Do you have high blood pressure? include that and list the stats on hiigh blood pressure and how it relates to the obese, finally complie a listing of all medications and treatments currently prescribed (include cpap) and attach it to the rest of the stuff, any dated photos of yourself going back as far as you can, show them with pictures, the lifelong struggles of obesity. It certainly couldnt hurt. Im with you in spirit as you make this trip, remain positive, it is going to work this time. Love, Sandy

Dr. B wrote an excellent article for publication on obesity, you can either print it out and attach it with the others or paraphrase to get your point across but perhaps it will help them understand better the seriousness of your condition. Many insurance companies are not staffed with those specially trained in the treatment of obesity, just general MD's and RN's to review your case. The article may help the MD looking at your case to understand it better from another physcians perspective. Just an idea. http://www.universityassociatespc.com/usapc/treatment_paper.asp Sandy