Question:
Do you all think this letter from PCP will work for my insurance?

Hey guys and gals! I got a referal to my surgeon from my PCP. This letter will also go to my insurance provider, BLUE CROSS/BLUE SHIELD of TEXAS. From experience, do you think this will work for pre-approval? Let me know! : ) -Nancy To Whom It May Concern: This 32-yr-old white female was seen on 9/18/06 for a referral for a gastric bypass. Patient states she has sleep apnea & has episodes where she does not breathe. Patient is also here for a medical evaluation. Patient had elevated blood pressure of 124/93 & pulse of 91. Laboratory data was taken & patient had elevated triglycerides of 270, low HDL. ASSESSMENT: 1. Sleep Apnea 2. Hypertension 3. Dyslipidemia. PLAN: I feel that the patient is an excellent candidate for gastric bypass & needs that because of her health problems of hypertension, dyslipidemia & sleep apnea. These could cause detrimental affects to her health if not treated. I feel she needs gastric bypass. Signed: my doctor.    — 1fatgurl (posted on September 25, 2006)

September 25, 2006
Hi Nancy, I do not live even near Texas, but I may be able to give you some advice on this. First I think that that letter is good but needs some improvement before getting sent to your insurance company. It needs to state that this surgery is "MEDICALLY NECESSARY" for you cause of so and so reasons. Second, have you had a sleep test to MAKE FOR CERTAIN that you have sleep apnea? Just stating it is not going to do for an insurance company, there has to be proof. I would suggest getting a polysomnography(sleep test) test done before sending that letter to determine whether or not it is actually sleep apnea. Also make sure that you have all the documentation of what types of diets, etc you have tried in that letter. Also what types of Co- morbidities that you have( such as the sleep apnea, dyslipidemia, and hypertension, others you may want to include could be( if you have these) back pain, joint pain, limitations on daily activities( tying shoes, bathing, etc) will be very helpful to list too. Mabye you might even want them to know that you have done tremendous research and know what you are getting your self into. They want everything about you and want to know all the things you have tried at and failed before giving you this approval. They may even require you to do a 6 month supervised diet, so be prepared for that if they request it. I would HIGHLY RECOMMEND LOOKING into a book that I got just this last week labled " Weight Loss Surgery: Finding The Thin Person Inside You!" By Barbara Thompson. It has everything that you need to know in it about undergoing this procedure and you would find it very helpful in writing this letter to your insurance company. The website that you can go to get that book is: www.wlscenter.com. I hope this helps!!
   — C. Reed

September 25, 2006
I think it is a good letter--but I agree with the previous poster, it should say "MEDICALLY NECESSARY". Good luck to you.
   — tylerswife

September 25, 2006
Hi there! I am a fellow BCBS of TX person. Now, I don't want to burst your bubble, because everyone's experience is different. For me, BCBS requires a 12 month medically supervised diet, and they mean it. I have 5 straight years of Weight Watchers books, and they won't even entertain any of it. Have you called BCBS of TX to talk about your policy specifically? Sometimes that first person you get on the phone is not looking deep enough into the requirements -- that's what happened to me initially. I got all excited, only to find out after about the MD super-diet. It was a party-breaker, for sure. I agree with the other noters though, the letter needs a little more substantiation of the surgery. I found the best way to go is to find a surgeon, and let his office tell you who to see. Chances are they work with an internal medicine/general practioner who knows how to write these letters on your behalf. I had the sleep apnea test done, and I do have it. I just required a couple nights (separately) away from home, but it was worth it. I got a c-pap machine, and my sleep is better and wake up feeling overall better --it's not dramatic, but I can feel the difference. BCBS PPO paid every last cent of the Sleep Study and for the high-end sleep machne that my PCP insisted on. I hope this helps. Good luck.
   — donnainhouston

September 25, 2006
Hi Nancy, I have BCBS of Ohio and my PCP did not say it was a medical neccesity but he did have to list what diets I have tried in the past and also my weight history for the past 5 years. If you call your insurance carrier they will tell you exactly what you need to be approved. I was approved first time but I also did my research first with BCBS to make sure I had everything. Best wishes! Diane
   — deeport

September 25, 2006
My secondary insurance is BCBS of Texas and I was approved on 3 months of physician supervised diet. Don't know if they just 'accept" what my primary wanted (3 months). I can believe that they would accept that "the patient states she has sleep apnea". I would think you would need proof - i.e. a sleep test report. I would think it would be better if medical necessity was added. Sorry I can't be much more help.
   — KC

September 30, 2006
I agree it must say medical nessesity I also wrote a letter my self telling why it was important to me and how it affected my life and my familys life and the everyday struggles of living and all the harassment from people good luck
   — brandy3333

October 2, 2006
Find out what your insurance requirs and meet the requirements. It helps if you get a sleep study and are being treated for the sleep apnea.
   — Novashannon