Question:
Letter of Necessity vs. Letter I got from PCP

Today in the mail I received the letter of necessity from my PCP. I had taken a letter in to her to copy but when I got it today I noticed that she had changed the whole context of my letter. Instead of being a letter of necessity she made it into a letter for evaluation. She wrote things like "I would like her to be evaluated" and "I am referring this patient for evaluation" My question is: Do you think this letter from her is going to help me to get insurance approval? Thanks in advance,    — Darlene C. (posted on January 18, 2003)

January 18, 2003
This letter sounds more like a referral letter from your PCP to a surgeon. Perhaps that what your PCP thought was requested?
   — Diane M.

January 18, 2003
My back dr.and my PCP wrote a letter, both never used the word medically necessary. I guess they only consider medical necessity life or death and I wasn't at that point, yet. It was my surgeons policy to not even send the letters on the first request. Turns, out I didn't need it after all. A BMI over 40 puts you at a level of necessity to start with. What are your co-morbids?
   — Heather S.

January 19, 2003
Depending on the insurance you have your PCP may have done exactly what is needed. I am assuming the letter is addressed to your insurance company. If you have an HMO it is possible that she has to get the insurance company's approval in order to refer you to a surgeon for THIS particular surgery, versus something like galbladder she would be able to refer directly. If you have a PPO it may also be the same. Look at your insurance book - that might answer this. If you have a fee for service then skip the PCP and go directly to the surgeon and him or her write the letter of medical necessity. That's what I did. I provided him with all the info and he wrote it. My internist was in favor but with his patient load I could still be waiting for that letter instead of winding down to surgery in 2 weeks. Good Luck!
   — zoedogcbr

January 19, 2003
Heather, my co-morbitities are high blood pressure, high cholesterol, high triglycerides, shortness of breath and more. Diane, I gave the PCP a copy of a letter of Necessity to copy. She changed the whole context to an evaluation. Or as you said it sounds like she wrote this letter to the surgeon instead of the insurance company.
   — Darlene C.

January 19, 2003
I am so glad to read a letter about this same thing. I have been worried since receiving my letter also. My letter states that I am a well controlled diabectic hypertension hypothyroidism with the use of a cpap for sleep apnea.and over all in reasonably good health and that I would benefit greatly from the surgey for all the above that I have stated. My Dr never mentioned the term medically necessary. All this is directed to the surgeon. I hope that I am worrying for nothing and this is good enough to get me approved for the surgery. Barbara Tourreuil [email protected] Elko Nv Would love to hear fom those in the western States.
   — Barbara T.

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