Doctors Recommendation
My PCP will support my WLS but has asked me to put together the draft
copy of a letter to be submitted to the surgeon who will be
performing the operation. I am stuck trying to put in information
that the insurance company will use in making the assessment. Any
suggestions would be appreciated. Thanks
December 24th, 2005 at 8:02 pm
My PCP will support my WLS but has asked me to put together the draft
copy of a letter to be submitted to the surgeon who will be
performing the operation. I am stuck trying to put in information
that the insurance company will use in making the assessment. Any
suggestions would be appreciated. Thanks
December 25th, 2005 at 2:27 am
I found this on obesityhelp.com
I hope it helps you…good luck
WRITE YOUR LETTER
Ok….Here comes the hard part !! It really doesn’t have to be hard though because
we are going to walk you through with some sample letters that can be edited for
you personally. The letter you write to your insurance company is one of your
most important tasks. You need to get it right the first time !!
How to write your letter: (you can use the sample below)
Use any of the comorbid conditions ( comorbid conditions are the ones with *
or ** ) that apply to you.
*means use this if it applies to you.
**means use either this one or the next one that will also have 2 stars.
Use any of the diet plans that apply to you.
Here we go:
The name and address of your insurance company
Re: Your name:
Group No:
Identification No:
Request for Pre-approval for Gastric Bypass
(CPT-4 Code = 43847)
Note: (I meet both Milliman and Robertson and U.S. Federal Guidelines)
Milliman and Robertson Guidelines for the Gastric Surgery for Clinically
Severe Obesity 15 CPT-4: 43847
AND,
U.S. Federal Clinical Practice Guidelines for the Treatment of Obesity set
down in National Institutes of Health Consensus Conference. Released June 17,
1998, the Federal guidelines on obesity were by the National Heart, Lung, and
Blood Institute (NHLBI), in cooperation with the National Institute of Diabetes
and Digestive and Kidney Diseases (NIDDK)).
Dear Sir;
I am writing to request your pre-approval for gastric bypass surgery (Diagnosis
Code 278.01 Procedure Code 43847)
I am _____ft_____inches tall and I weigh _______pounds. My body mass index is
_____. 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 am
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 _____ percent increased risk
of death at my present weight.
I ask for your pre-approval for this surgery. I will detail the issues of
medical necessity.
I am having significant adverse symptoms from my obesity. I have difficulty
standing, and in doing any kind of exercise, even walking more than a short
distance. I have difficulty performing any daily activities, and in
participating with my family in recreational activities.
*I suffer from stress incontinence and have to wear protective pads at all
times. A large heavy abdomen, and relaxation of the pelvic muscles, especially
associated with the effects of childbirth, may cause the valve on the urinary
bladder to be weakened, leading to leakage of urine with coughing, sneezing, or
laughing. This condition is strongly associated with being overweight, and is
usually relieved by weight loss.
**I have sleep apnea. Sleep apnea — the stoppage of breathing during sleep –
is common in the clinically severe obese. The health effects of this condition
may be severe. It has been estimated that up to 50 percent of sleep apnea
patients have high blood pressure. Risk for heart attack and stroke also
increase in those with sleep apnea. People with sleep apnea often feel very
sleepy during the day and their concentration and daytime performance suffers.
The consequences include depression, irritability, sexual dysfunction, learning
and memory difficulties, and falling asleep while at work, on the phone, or
driving. This condition has a high mortality rate, and is a life-threatening
problem. People are usually cured of sleep apnea by this surgery and the
permanent weight loss it brings.
**I have sleep disturbances and one doctor suggests a sleep study for sleep
apnea. The weight loss would help with sleep disturbances and cure sleep apnea.
*I am diabetic. In addition to being a morbid and lethal disease, diabetes has
been shown to be very expensive to treat. Rubin et. al. in a study in 1992
showed that yearly health care expenditures for confirmed diabetics ($11,157)
were more than four times greater than for nondiabetics. In 1992, diabetics
constituted 4.5% of the U.S. population but accounted for 14.6% of total U.S.
health care expenditures ($105 billion). Confirmed diabetics constituted 3.1% of
the U.S. population but accounted for 11.9% of total U.S. health care
expenditures ($85 billion). Health care expenditures for people with diabetes
constituted about one in seven health care dollars spent in 1992. (Diabetes in
America, 2nd Edition, The National Institutes of Diabetes and Digestive and
Kidney Diseases, 1995, NIH publication number 95-1468.) Health care insurers
should take note of these findings. Gastric Bypass has been shown to cure
diabetes and thus it is cost effective for insurers to pay for surgery to cure
diabetes and prevent its complications. Nearly 80 percent of patients with NIDDM
are obese.
*I also suffer from high blood pressure. Essential hypertension, the progressive
elevation of blood pressure, is much more common in obese persons, and leads to
development of heart disease, and damage to the blood vessels throughout the
body, causing susceptibility to strokes, kidney damage, and hardening of the
arteries. If hypertension is not under control, many complications can occur as
a direct result of continued high blood pressure. 60% of hypertensive people are
obese. The weight loss attained by gastric bypass surgery will cure
hypertension.
*I have gastroesophageal reflux disease (GERD). This condition is dangerous,
because of the possibility of pneumonia or lung injury. The esophagus may become
scarred and constricted, causing trouble with swallowing. Approximately 10 - 15%
of patients with even mild sporadic symptoms of heartburn will develop a
condition called Barrett’s esophagus, which is a pre-malignant change in the
lining membrane of the esophagus, a cause of esophageal cancer. Pathologic
conditions associated with GERD include erythema, isolated erosion, confluent
erosions, circumferential erosions, deep ulcers, esophageal stricture,
replacement of normal esophageal epithelium with abnormal (Barrett’s)
epithelium, pulmonary aspiration, chronic cough, and reflux laryngitis.
*Also, I have high cholesterol. When there is too much cholesterol in your
blood, the excess can become trapped in the walls of your arteries. By building
up there, the cholesterol helps to cause hardening of the arteries or
atherosclerosis. And atherosclerosis causes most heart attacks. How? The
cholesterol buildup narrows the arteries that supply blood to the heart, slowing
or even blocking the flow of blood to the heart. So, the heart gets less oxygen
than it needs. This weakens the heart muscle, and chest pain (angina) may occur.
If a blood clot forms in the narrowed artery, a heart attack (myocardial
infarction) or even death can result.
*Arthritis is a major comorbid condition that I have. One of the nearly
intolerable problems is the constant pain of the weight-bearing joints. An
increase in body weight adds trauma to weight bearing joints and excess body
weight is a major predictor of osteoarthritis. This is a mechanical problem and
not a metabolic one. The hips, knees, ankles and feet have to bear most of the
weight of the body. These joints tend to wear out more quickly, or to develop
degenerative arthritis much earlier and more frequently, than in the
normal-weighted person. Eventually, joint replacement surgery may be needed, to
relieve the severe pain. Unfortunately, the obese person faces a disadvantage
there too — joint replacement has much poorer results in the obese. Many
orthopedic surgeons refuse to perform the surgery in severely overweight
patients. The permanent weight loss of gastric bypass surgery will markedly
decrease problems with arthritis and the ever-increasing expenses to the
insurance companies that will surely follow.
* I suffer from venous stasis disease. The veins of the lower legs carry blood
back to the heart, and they are equipped with an elaborate system of delicate
one-way valves, to allow them to carry blood "uphill". The pressure of a large
abdomen may increase the load on these valves, eventually causing damage or
destruction. The blood pressure in the lower legs then increases, causing
swelling, thickening of the skin, and sometimes ulceration of the skin. Weight
loss after gastric bypass can relieve venous stasis disease.
* I have hypercholesterolemia (high cholesterol). When there is too much
cholesterol in your blood, the excess can become trapped in the walls of your
arteries. By building up there, the cholesterol helps to cause hardening of the
arteries or atherosclerosis. And atherosclerosis causes most heart attacks. How?
The cholesterol buildup narrows the arteries that supply blood to the heart,
slowing or even blocking the flow of blood to the heart. So, the heart gets less
oxygen than it needs. This weakens the heart muscle, and chest pain (angina) may
occur. If a blood clot forms in the narrowed artery, a heart attack (myocardial
infarction) or even death can result.
*Because of my weight, I am depressed. Seriously overweight persons face
constant challenges to their emotions: repeated failure with dieting,
disapproval from family and friends, sneers and remarks from strangers. They
often experience discrimination at work, and cannot enjoy theatre seats, or a
ride in a bus or airliner. There is no wonder, that anxiety and depression might
accompany years of suffering from the effects of a genetic condition — one
which skinny people all believe should be controlled easily by will power.
I suffer from depression related to obesity and I am on_________________ to
treat it.
*Coronary artery disease is another problem caused by clinically severe obesity.
Severely obese persons are approximately 6 times as likely to develop heart
disease as those who are normal-weighted. Coronary disease is pre-disposed by
increased levels of blood fats, and the metabolic effects of obesity. Increased
load on the heart leads to early development of congestive heart failure.
Severely obese persons are 40 times as likely to suffer sudden death, in many
cases due to cardiac rhythm disturbances.
*I become short of breath on any exertion. I cannot climb even one flight of
stairs without stopping, and have a very difficult time performing the ordinary
day-to-day duties of living, such as shopping, cleaning, getting in and out of a
car or chairs, or to board a bus. I was once physically active, playing sports,
and enjoying gardening, but at this time, I find that I am unable to perform any
recreational activity, and feel depressed because I cannot control or lose the
weight. Climbing stairs or even walking short distances causes the obese to
become very short of breath. Obese persons find that exercise causes them to be
out of breath very quickly. The lungs are decreased in size, and the chest wall
is very heavy and difficult to lift. At the same time, the demand for oxygen is
greater, with any physical activity. This condition prevents normal physical
activities and exercise, often interferes with usual daily activities, such as
shopping, yard-work or stair climbing, and can be completely disabling. Losing
weight will cure respiratory problems.
*I have been diagnosed with Obesity Hypoventilation Syndrome. This condition
occurs primarily in the very severely obese — over 350 lbs. It is characterized
by episodes of drowsiness, or narcosis, occurring during awake hours, and is
caused by abnormalities of breathing and accumulation of toxic levels of carbon
dioxide in the blood. It is often associated with sleep apnea, and may be hard
to distinguish from it. After gastric bypass and the weight loss it brings, OHS
will be relieved with weight loss.
*I have chronic skin problems. I am in a constant battle with yeast infections
and chronic rashes in the folds of my body. The obesity causes these skin folds
so that skin rubs on skin and the moisture trapped in those creases cause the
infections and rashes.
I have made many attempts to lose weight, including
Weight Watchers
Jenny Craig
NutraSystem
Herbal Life
Atkins diet
Mayo Clinic Diet
Nutritionist consults
Hypnotism
Acupuncture
Gym memberships
Richard Simmons
Redux
Meridia
Phen-fen
Xenical
Pondimin
……and many of the over-the-counter diet plans and diet medications.
I have included exercise with all weight-loss attempts. I can lose some weight,
but then I gain it all back and more. There is not one study that shows that
dieting brings permanent weight loss. The National Institutes of Health, in 1991
and 1992 consensus statements, rebutted conventional diets for morbid obesity,
and pointed to this important fact: Diets alone cannot be successful for the
morbidly obese.
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. For patients
with BMIs greater than 30, the study also showed increases in health care costs
related to diabetes and hypertension.
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 my case, are not effective. Rather it can
expected that I will continue to gain weight over the ensuing years and add to
this present list of obesity associated illnesses.
Seriously obese persons suffer inability to qualify for many types of
employment, and discrimination in employment opportunities, as well. They tend
to have higher rates of unemployment, and a lower socioeconomic status. Ignorant
persons often make rude and disparaging comments, and there is a general
societal belief that obesity is a consequence of a lack of self-discipline, or
moral weakness. Many severely obese persons find it preferable to avoid social
interactions or public places, choosing to limit their own freedom, rather than
suffer embarrassment.
I do not want the surgery just so I can look great. I need it for health
reasons, as you can see. I ask that you pre-approve this surgery so that I can
become a healthy, productive person once again. Thank you very much for your
consideration.
Sincerely,
____________________
Your name
Kelley
December 25th, 2005 at 8:38 pm
Hi Car2331, ( Sorry but you didn’t leave your name) I wanted to tell you that I
am in the process of being approved and I have found that the Obesityhelp.com
website gives a lot of information for everything you might have to go through
in getting approval and for the surgery itself. They have a couple sample
letters that might give you the format you need to send to your surgen. Hope
that helps. Good luck!