Who writes Letter of Medical Necessity, plastic surgeon or PCP?

I am having a hernia repair in November and would like to get a tt at the same time. Who would write the letter to my insurance co? I have made complaints about my back pain to my PCP, he doesn't have a clue that it would be related to my belly. He knows I want a tt and suggested that I wait until I heal from the hernia repair! I have not had any rashes. My RNY surgeon says the PCP has to write the letter. How do I approach him? HELP Please!

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