Question:
Do you all think this letter from PCP will work for my insurance?
Hey guys and gals! I got a referal to my surgeon from my PCP. This letter will also go to my insurance provider, BLUE CROSS/BLUE SHIELD of TEXAS. From experience, do you think this will work for pre-approval? Let me know! : ) -Nancy To Whom It May Concern: This 32-yr-old white female was seen on 9/18/06 for a referral for a gastric bypass. Patient states she has sleep apnea & has episodes where she does not breathe. Patient is also here for a medical evaluation. Patient had elevated blood pressure of 124/93 & pulse of 91. Laboratory data was taken & patient had elevated triglycerides of 270, low HDL. ASSESSMENT: 1. Sleep Apnea 2. Hypertension 3. Dyslipidemia. PLAN: I feel that the patient is an excellent candidate for gastric bypass & needs that because of her health problems of hypertension, dyslipidemia & sleep apnea. These could cause detrimental affects to her health if not treated. I feel she needs gastric bypass. Signed: my doctor. — 1fatgurl (posted on September 25, 2006)
September 25, 2006
Hi Nancy,
I do not live even near Texas, but I may be able to give you some advice on
this. First I think that that letter is good but needs some improvement
before getting sent to your insurance company. It needs to state that this
surgery is "MEDICALLY NECESSARY" for you cause of so and so
reasons. Second, have you had a sleep test to MAKE FOR CERTAIN that you
have sleep apnea? Just stating it is not going to do for an insurance
company, there has to be proof. I would suggest getting a
polysomnography(sleep test) test done before sending that letter to
determine whether or not it is actually sleep apnea. Also make sure that
you have all the documentation of what types of diets, etc you have tried
in that letter. Also what types of Co- morbidities that you have( such as
the sleep apnea, dyslipidemia, and hypertension, others you may want to
include could be( if you have these) back pain, joint pain, limitations on
daily activities( tying shoes, bathing, etc) will be very helpful to list
too. Mabye you might even want them to know that you have done tremendous
research and know what you are getting your self into. They want everything
about you and want to know all the things you have tried at and failed
before giving you this approval. They may even require you to do a 6 month
supervised diet, so be prepared for that if they request it. I would HIGHLY
RECOMMEND LOOKING into a book that I got just this last week labled "
Weight Loss Surgery: Finding The Thin Person Inside You!" By Barbara
Thompson. It has everything that you need to know in it about undergoing
this procedure and you would find it very helpful in writing this letter to
your insurance company. The website that you can go to get that book is:
www.wlscenter.com. I hope this helps!!
— C. Reed
September 25, 2006
I think it is a good letter--but I agree with the previous poster, it
should say "MEDICALLY NECESSARY". Good luck to you.
— tylerswife
September 25, 2006
Hi there! I am a fellow BCBS of TX person. Now, I don't want to burst
your bubble, because everyone's experience is different. For me, BCBS
requires a 12 month medically supervised diet, and they mean it. I have 5
straight years of Weight Watchers books, and they won't even entertain any
of it.
Have you called BCBS of TX to talk about your policy specifically?
Sometimes that first person you get on the phone is not looking deep enough
into the requirements -- that's what happened to me initially. I got all
excited, only to find out after about the MD super-diet. It was a
party-breaker, for sure.
I agree with the other noters though, the letter needs a little more
substantiation of the surgery. I found the best way to go is to find a
surgeon, and let his office tell you who to see. Chances are they work
with an internal medicine/general practioner who knows how to write these
letters on your behalf.
I had the sleep apnea test done, and I do have it. I just required a couple
nights (separately) away from home, but it was worth it. I got a c-pap
machine, and my sleep is better and wake up feeling overall better --it's
not dramatic, but I can feel the difference.
BCBS PPO paid every last cent of the Sleep Study and for the high-end sleep
machne that my PCP insisted on.
I hope this helps. Good luck.
— donnainhouston
September 25, 2006
Hi Nancy, I have BCBS of Ohio and my PCP did not say it was a medical
neccesity but he did have to list what diets I have tried in the past and
also my weight history for the past 5 years. If you call your insurance
carrier they will tell you exactly what you need to be approved. I was
approved first time but I also did my research first with BCBS to make sure
I had everything. Best wishes! Diane
— deeport
September 25, 2006
My secondary insurance is BCBS of Texas and I was approved on 3 months of
physician supervised diet. Don't know if they just 'accept" what my
primary wanted (3 months). I can believe that they would accept that
"the patient states she has sleep apnea". I would think you
would need proof - i.e. a sleep test report. I would think it would be
better if medical necessity was added. Sorry I can't be much more help.
— KC
September 30, 2006
I agree it must say medical nessesity
I also wrote a letter my self telling why it was important to me and how it
affected my life and my familys life and the everyday struggles of living
and all the harassment from people good luck
— brandy3333
October 2, 2006
Find out what your insurance requirs and meet the requirements. It helps
if you get a sleep study and are being treated for the sleep apnea.
— Novashannon
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