Letter to Insurance Company (AETNA)
I've posted before about my concerns at not having a consistent BMI over 40 (I'm now 41.8 but was 38.2 in 2013 and 2014 due to diets I was on. I've been losing and gaining since age 11).
My PCP is writing me a letter of necessity, but I thought I would also include a letter of my own. Do you think this will help sway the medical director into approving my surgery. I'd really appreciate your thoughts!
To whom it may concern:
My name is XXXXX, and I am seeking approval for bariatric surgery.
I am 43 years old and have been obese since childhood. I weighed 200 pounds at age 14, 248 pounds at age 23, 233 pounds at age 33, 238 pounds at age 41, 252 pounds at age 43. In the last 5 years, I have fluctuated between 230-255 pounds, with a BMI that alternates from 38-42. I have pursued a variety of diet and exercise programs over many years, but I have been unable to reach and maintain a healthy weight. I am writing this letter to ask for your help.
I have been dieting and exercising since my teen years. I have tried low-fat, low-calorie, low-carbohydrates, weight training, aerobics, running and swimming. From 2006-2009, I was on the Atkins diet, diligently staying under 20g of carbohydrates per day. This diet was relatively successful, and allowed me to maintain a fluctuating weight of approximately 200-210 pounds but, in the end, the austerity of the plan was not sustainable and the pounds were regained, plus some. From 2010-2011, I was on Nutrisystem, which resulted in a 10 pound weight loss that saw me eating a lot of freeze-dried, heavily-processed foods. The pounds lost from that were also quickly regained, plus some. In 2013, I was on doctor-prescribed Phentermine, maintained a diet of 800 calories per day and lost 8 pounds, 6 of which were regained when I increased my calorie consumption to a more reasonable 1200 calories a day. In 2014, I paid $130/week for 1,200 calorie per day meals from Diet2Go and lost 5 pounds, which were regained. These are only a few of the weight loss attempts I have made over the last 29 years. I can honestly say that I am on a diet more often than I am not.
I have been physically active throughout my weight loss attempts, always walking, sometimes running, always choosing the stairs over the elevator. I try to stay active as my body will allow yet, in spite of continuous diet and exercise, my weight has been on a steady incline and, as I grow older, it becomes more and more difficult to stop the pounds from piling on. I fear that without bariatric surgery, the best I can hope for at this time is maintaining the weight I am now.
I have been on a high-protein, low calorie diet for the last three months, have been recording my diet and exercise and have been meeting with a nutritionist on a regular basis, who seems to agree that I am doing a good job of staying on plan.
10 weeks ago, I ended a pack a day, 30-year smoking habit and, while I haven’t managed to lose a substantial amount of weight during this ongoing period of smoking cessation, I also have not seen the net gain that typically comes with the quitting process.
Today, at 43 years old, I weigh 250 pounds which, as a 5’5 woman with a petite frame, exceeds my physician-suggested weight by 120 pounds. My body is straining to support this excess weight, and I am feeling the effects of that strain quite markedly. I am suffering from urinary incontinence, heartburn, shortness of breath and severe joint pain, particularly in my knees. My back aches and I suffer from muscle spasms. The circulation in my lower extremities is poor. Exercise is becoming more and more difficult for me, specifically due to severe knee pain and shortness of breath. Despite having a long history of moderate physical activity, something as minor as climbing two flights of stairs now leaves me completely winded, perspiring and with heart racing. At the time of my initial surgical consult, my blood pressure was the highest it has been to date (140/86), as was my heart rate (102 BPM). I fear that, without the benefit of weight loss surgery, I will soon see a rapid decline in overall health and in basic mobility and will require orthopedic surgeries, physical therapies, and a lifetime tests and medications.
I have an immediate family history of diabetes, heart disease, heart attack, high cholesterol, hypertension and cancer. My father (deceased), my paternal grandmother (deceased), my paternal aunt, my maternal-aunt (deceased) and all three of my siblings suffer from or have suffered from persistent obesity. My propensity is to carry the majority of my excess weight in my midsection (my waist circumference is 49 inches), which I understand increases my risk of heart disease, cervical cancer and diabetes and this is of great concern to me.
I am including pictures of various years, from age 17 to present, which demonstrate persistent obesity. Like most obese persons, I often hid from the camera and now only have a handful of photos, but I hope this helps to give you a visual history of my ongoing weight problem.
I recognize that weight loss surgery is not an answer, but a tool. I am aware that the outcome of the surgery is entirely dependent upon me. I do feel that I’m well-prepared, dedicated and disciplined enough to effectively use that tool to become a Weight Loss Surgery Success Story. I hope very much that you’ll give me the chance to do so. You would truly be saving my life, and I promise that I will not let you down.
Thank you for your consideration.
With Aetna which paid for mine I am pretty sure it is 40 BMI with no comorbidities and 35 with them. I was at like 62 so no problem but I also had sleep apnea. I honestly don't think that letter will make any difference. They have set guidelines and as long as you meet them then they will approve you. Good luck.
I may be in trouble then, as I had a 38.5 BMI in 2013/2014, and I don't believe Aetna considers high cholesterol, prehypertension, elevated glucose, osteoarthritis or urinary incontinence to be co-morbidities. So I guess I'll have to wait until I formally develop diabetes, heart disease and full on hypertension, which will likely occur within the next couple of years. Hopefully, I'll not need to have a knee replacement before that occurs.
Ironically, if Aetna denies my claim, they'll probably pay out more $$ to care for my obesity-related ailments than to treat the obesity itself.
Yes, I have done all the research and have spoken with a Bariatric Guru at Aetna (twice). Aetna changed their language recently where, instead of asking for a 2 year history of severe obesity, they ask for a history of persistent contemporaneous severe obesity. I asked the Guru if the 38 BMI would disqualify me, as I was only a 38 because I was intensely dieting and she said that they wouldn't necessarily deny me for BMI; She said that the medical director will look at everything before making a final decision. The co-morbidities Aetna lists are sleep apnea, diabetes, heart disease and hypertension. I have PREhypertension, I don't have diabetes YET, and I've never been tested for heart disease or sleep apnea. So, we're submitting with the 2015 BMI of 41, the letter of necessity from my PCP, my letter to Aetna, and I'm going to include pictures from childhood to present that show how heavy I am.
But, still, they'll probably deny me for that damn 38 BMI 
