Question:
Question about Letters of Medical Necessity from PCP
Hi...I have been looking through the library to find sample letters to the insurance company stating the insurance is needed for medical necessity, but haven't had any success. Almost all of the information I found regarding this referred going to www.clos.net/insurlet but it states that the page cannot be found, so I even tried going to www.clos.net and browsing through the site and found no sample letters to insurance companies of any kind. Does anyone have any type of recommendation or sample as to what my PCP should write to the insurance company stating that the surgery is medically necessary. Any help is greatly appreciated! You can e-mail me at [email protected] - thanks again! — Giovanna G. (posted on May 16, 2002)
May 16, 2002
Go to ask a question and type in sample letters.
— Lisa W.
May 16, 2002
Hi Lisa...I have done that, but actual samples of letters from a doctor
stating medical necessity are not there. Most of the posts regarding this
question mention to go to the website that I stated in this original post,
which can no longer be found. They do not have sample letters posted on
their site anymore. I have done a few different searches in the library to
find letters, but have come up with nothing.
— Giovanna G.
May 16, 2002
I have several letters I have written and can hook you up with a
site--email me and I will send from work--my disk is there---
— Linda L.
May 16, 2002
Is a letter like this always necessary, or does it depend on your
insurance? I've heard of people writing letters to their insurance, too,
and don't know if that will be necessary or not. My PCP did write a letter
for me to take to my surgeon consult w/me, which is next week. I'm getting
excited!!!!!
— Want2bslim
May 16, 2002
Click on my profile and scroll down to my 6 month mark and you'll find a
copy of the letter from my PCP to the insurance company. Worked like a
charm! =)
— Jeannet
May 16, 2002
Click on my profile and scroll down to my 6 month mark and you'll find a
copy of the letter from my PCP to the insurance company. Worked like a
charm! =)
— Jeannet
January 4, 2005
I found the link on this website, you just need to scroll down. It is a
sample letter.
http://www.obesityhelp.com/morbidobesity/showquestions.phtml
Sherry D
— Sherry D S.
January 4, 2005
Sample Appeal Letter
Dear Sir,
This letter is to appeal your denial for RNY gastric bypass surgery
(Diagnosis Code 278.01 Procedure Code 43847).
I was referred for this surgery by my PCP, who is very concerned about my
health because of severe morbid obesity. I am a ___ year old morbidly obese
male who is ______tall and weigh ______ lbs., giving me a body mass index
of________. The body mass index is calculated by dividing a person's weight
in kilograms by their height in meters squared. When a man's BMI is over
27.8, or woman's exceeds 27.3, that person is considered obese. The degree
of obesity associated with a particular BMI ranges from mild obesity at a
BMI near 27, moderate obesity at a BMI between 27 - 30, severe obesity at
30 - 35, to very severe obesity for patients with a BMI of 40 or greater
1,2,3. Therefore, I may be 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 year4,5. With my abnormally high BMI, I
am at an estimated 190 percent increased risk of death at my present
weight.
I am having significant adverse symptoms from my obesity. I have difficulty
standing. I have difficulty performing my daily activities, and in
participating with my family in recreational activities. I have arthritis
and pain of my weight-bearing joints. An increase in body weight adds
trauma to weight bearing joints and excess body weight is a major predictor
of osteoarthritis of the knees. This is a mechanical problem and not a
metabolic one. Weight loss will markedly decrease the chance of developing
osteoarthritis.
I also suffer from shortness of breath. There are several abnormalities in
pulmonary function in obese individuals. At one extreme are patients with
so-called Pickwickian syndrome, or the obesity-hypoventilation syndrome,
which is characterized by somnolence and hypoventilation; it eventually
leads to cor pulmonale. In patients who are less obese, there is a fairly
uniform decrease in expiratory reserve volume and a tendency to reduction
in all lung volumes. A low maximum rate of voluntary ventilation and venous
admixture is also present. As an individual becomes more obese, the
muscular work required for ventilation increases. In addition, respiratory
muscles may not function normally in obese individuals.
Because of my acid reflux and pains and aches in my back and legs I have
difficulty sleeping, and therefore, am fatigued and tired during the day.
This surgery usually cures acid reflux and sleep disturbances.
I have borderline hypertension at this point. Hypertension is a common
concomitant of obesity.
I now have bone spurs on both my feet that are aggravated by my weight.
I have made many, many attempts to lose weight and this has gone on all my
life. I was put on medications by my doctor to help lose weight. I have
been put on medications over and over again. I would lose some weight then
gain it all back, and more. I have also tried many exercise programs. I
have tried Nutri-System. My primary care physician put me on Redux. As you
can see, I have spent all my adult life trying to lose weight. I am now at
the very edge of complete disability and am at a point where everything is
an effort. The obese individual has functional impairment in the activities
of daily living. This dysfunction impacts sleep, recreation, work and
social interactions.
Economic costs of Obesity:
Obesity has been shown to directly increase health care costs. In an
article in the March 9, 1998, issue of the Archives of Internal Medicine
17,118 members of the Kaiser Permenente Medical Care Program were studied
to determine the association between body fatness and health care costs.
The results showed that patients with BMIs greater than 30 had a 2.4 times
greater risk for increased inpatient and outpatient costs than patients
with BMIs under 30.
Indirect 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 is evidenced in this case, are not
effective. Rather it can expected that he will continue to gain weight and
the costs of co-morbid conditions, including the ones he already has and
ones he surely will acquire as time goes on, will far outweigh the costs of
gastric bypass surgery that we are asking you to please approve for this
gentleman.
As you can see I have exhausted all the traditional ways to lose weight.
The gastric bypass is an approved and proven means to permanently lose
weight. Please approve this surgery for me. Thank you.
Sincerely,
Reference Sources:
1. Weighing the Options: Criteria for Evaluating Weight-Management
Programs. Institute of Medicine, National Academy of Sciences. 1995; 50-51.
2. Kuczmarski, R.J., Johnson, C.L., Flegal, K.M., Campbell, S.M. Increasing
prevalence of overweight among US adults. Journal of the American Medical
Association. 1994; 272:205-211.
3. Troiano, R.P., Kuczmarski, R.J., Johnson, C.L., Flegal, K.M., Campbell,
S.M. Overweight prevalence and trends for children and adolescents: The
National Health and Nutrition Examination Surveys, 1963 to 1991. Archives
of Pediatrics and Adolescent Medicine,1995; 149:1085-1091.
4. Daily dietary fat and total food-energy intakes: Third National Health
and Nutrition Examination Survey, Phase I, 1988-1991. MMWR Morbidity and
Mortality Weekly Report. 1994; 43:116-117, 123-125.
5. Weight control: What works and why. Medical Essay. Mayo Foundation for
Medical Education and Research, 1994
— Sherry D S.
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