Question:
anyone have any pointers on writing letter to the benefits devision for approval of w

My job is with a large corp. that has an exclusion to weightloss surgery but if my pcp says it is necessary i may get approval. I have the letter from my PCP but i also have to write a letter... Anyone have any ideas on what is an abosolute must for my letter?    — sheila T. (posted on January 20, 2003)

January 19, 2003
I am a nurse that works for an insurance company. Here is the biggest thing: stick to facts. (We have a pre-cert person that reviews all the appeal letters that come in, and she refers to some as "cry me a river" letters.) State your BMI, and mention any co-morbidities you may have. If you have labs out of whack - like elevated cholesterol or blood lipids, state what they are when last tested. If your blood sugars are elevated, say how high, even if you are not officially labeled "diabetic". If you have sleep apnea, use that. If being overweight affects your ability to get around, say how (ie, "I am limited to being able to walk XXX feet before becoming short of breath"), and if you have pain in your knees, ankles or hips, even your back. Avoid things like, "I really need this surgery to make my life better". Talk about how many diets (and be specific about what has been tried) you have been on, and how long you have been overweight. If you have a family history of morbid obesity, put that in the letter. Just stick to facts, and avoid an emotional plee for surgery.Hope this helps!
   — koogy

January 20, 2003
When I inquired about weight loss surgery I was right at 100lbs overweight, I had no co-morbities. My PCP said she would put in the referral but she doubted they would approve it being my weight was not contributing to any life threatening illness. I was denied. I wrote my appeal letter and in it I showed the obesity that ran in my family and every single diet I had been on, but the one thing I said In the letter(my PCP said it was the reason for the approval) was that I took ephedra every day just to manage my weight even at this point and I was so afraid that this is what was going to kill me because I knew it was dangerous but I felt I had no other choice. My PCP said they wouldn't want to be liable. I don't know id this is true but I got my approval 10 days after I mailed it. I'm now 2wks. post-op
   — Jennifer T.

January 20, 2003
I have just prepared my begging letter for approval from Pacificare. I work for a Healthcare consulting firm, so I got some AWP [average warehouse price - i.e. the price the HMO pays for the drug] of my current prescription medication as well as for future drugs for hypertension etc. I made a little table comparing annual prescription cost time 35 [assuming I live to age 65 I am 30 now] to get a lifetime prescription cost versus the $25-30k for surgery. I think it ended up being $200k v $25. I thought talking to them about their cash would get their attention. Not sure if it'll work but just a thought. Also I mentioned it did not included any future orthopedic/cardiac surgery costs that I may need if I stay obese. yvonne
   — Yvonne E.