Writing your Letter of Medical Necessity

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):

    1. Use any of the comorbid conditions (comorbid conditions are the ones preceded by a star (). One star means use this if it applies to you. Two stars means use either this one or the next one which will also have two stars.
    2. Use any of the diet plans that apply to you.

Here we go!

(Insert the name and address of your insurance company)
Re: (Insert your name here)
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:

  1. Milliman and Robertson Guidelines for the Gastric Surgery for Clinically Severe Obesity 15 CPT-4: 43847

    AND

  2. 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 or Madam:

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. Sixty percent 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 hypercholesterolemia (high cholesterol). When there is too much cholesterol in one's blood, the excess can become trapped in the walls of one's 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.

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. It 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 person 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 causes the infections and rashes.

I have made many attempts to lose weight, including:

  • Weight Watchers
  • 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 be 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 here)

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.