Medical Necessity Letter - ThinnerTimes - Gastric Bypass Forum, Lap Band Forum, and Vertical Sleeve Gastrectomy Forum

hummingbird5953 · 03-23-2007, 11:08 AM

Hi all,

I've just recently found the forum and have been touched and encouraged with the level of support from everyone here.

I've also recently made the decision to pursue Lap RNY and have only gotten so far as attending my surgeon's information session. Currently, I'm waiting to hear back from them to schedule the first in-office appointment.

I was hoping for insite that anyone might have in regard to the medical necessity letter. My insurance company only requires a letter of medical necessity from my primary care physician in order to approve the surgery. I called my pcp the other day and was told that I should fax them the letter saying what I want it to say, they will transfer it to their letterhead, and the doctor will sign it and send it back to me!

Seems kind of crazy that I'm allowed to write my own letter of medical necessity...but o.k. The problem is I have no idea what this letter should contain?!?!?

Any thoughts from those of you who have already obtained these letters?

Thanks, in advance!

mauldinmama · 03-23-2007, 11:13 AM

do you have any documented health issues? Are you taking any meds?

hummingbird5953 · 03-23-2007, 11:16 AM

No, fortunately/unfortunately, I'm totally healthy. I've just been overweight (and now morbidly obese - BMI 40.3) and getting heavier every year.
I'm also watching my obese mother fall apart at 54 and don't want that to be me in 20 years!
Even though I meet the NIH criteria, I'm terrified that I won't be approved for the surgery and want to do everything I can!

mauldinmama · 03-23-2007, 11:20 AM

Have you seen your weight lose surgery doc? Because that is who wrote my letter to insurance company.

He explained to me in 1991 they wrote the requirements for wls and they were 35-39 with co morbidities and over 40 without. so you meet the qualifications I would ask from help from the wls they have the experience thank transfer that to you pcp....

Good luck!

Deb2 · 03-23-2007, 11:24 AM

The letter should contain information about your attempts through the years to lose weight. The diets you've been on, how much you lost, for how long, how much you regained. Sheesh, I even had accupunture for weight loss. It was a joke--didn't even go back for a second session.

You should also explain family history of obesity and family history of diabetes, high blood pressure, ect.

I'm sure there will be more suggestions from others--these are just off the top of my head.

bridgetgirl · 03-23-2007, 11:27 AM

you need to get into your PCP so he can document your current weight, your blood pressure, you need labs to check your sugar and cholesterol levels.

Also, do you have back pain, knee pain, hip pain, ankle pain???? This is arthritis.

Have you been under the care or ever on prescription meds for weight loss?

There are so many more questions to ask, but lets just start with these. Usually a trip to your Dr to collect everything is ideal, bur hell we are creative here! It would be helpful to know if you have had rising blood pressure or rising blood sugars or are diabetic as well. Do you have sleep epnea? Do you sleep through the night?

Whew..... thats info we need for starters to help ya!

hummingbird5953 · 03-23-2007, 11:40 AM

I definitely have aches and pains...back, knees, ankles. I also broke my ankle about 4 years ago and sheared off all of the cartledge and the orthopedist said that I will experience degenerative arthritis if I continue to carry all of this weight.

I've never been under medical supervision for weight loss...although the bariatric surgeon said, in the info session, that I could be under their care for weight loss for up to 6 months to make the insurance company happy. I got Phenteramine (I think that's what it was) from my pcp back in the fall and it did zipadee-doo-da...I lost about 10 pounds and have gained back 20!

Even though it might make approval easier, I have to be honest and say that I don't have any of the co-morbidities. I'm really about as healthy as a horse and would like to keep myself that way which is why I'd like to have the surgery to help get this 100+ pounds off now!

I'm also concerned about the fact that I've done Weight Watchers and several of the other diet programs, but haven't saved receipts...until a friend opted to have the surgery done last year, it never occured to me to consider it for myself.

bridgetgirl · 03-23-2007, 12:00 PM

How long were you on Phentrmine? Thats a medically supervised diet.

hummingbird5953 · 03-23-2007, 12:02 PM

Quote:

Originally Posted by bridgetgirl

How long were you on Phentrmine? Thats a medically supervised diet.

2 or 3 months...silly me, I can't remember which, now. But I only saw the PCP when the Rx was first prescribed. Does that still count as medically supervised weight loss for 2 or 3 months?

bridgetgirl · 03-23-2007, 12:09 PM

Quote:

Originally Posted by hummingbird5953

2 or 3 months...silly me, I can't remember which, now. But I only saw the PCP when the Rx was first prescribed. Does that still count as medically supervised weight loss for 2 or 3 months?

If you weighed in that time period, and its documented in your chart.