Re: Sample Letter for Denials - Need Opinions Please

[Guest guest]

Dee,

It is a good letter. My only suggestion is that you add the

appropriate references to the medical literature, as it will add

credability to your statements. You can find numerous references and

information in " Hull's Folder " . In my " Aetna Letter " you will

find over 40 references which you can use.

Hull

> Hi, I got this sample letter from another site

> (obesityhelp.com?). I was going to give this to my

> PCP to use when he sends in the DS rec letter to my

> insurer as they say they won't cover the DS. What do

> you think of the content?

> _______________________________________

>

>

>

> RE: {PATIENT NAME}

> Patient ID {ID #}

>

>

> The above-named is under my care for {LIST

> CO-MORBIDITIES HERE}. The patient is ___ years old,

> ____ feet ___ inches tall and weighs ______ pounds

> with a body mass index of ____. Her super-morbid

> obesity is not being controlled by extreme dietary

> measures. {PATIENT NAME} is going to pursue gastric

> bypass surgery and we are supportive of her decision.

>

> {PATIENT NAME} has researched the various methods of

> gastric bypass surgery and has come to a decision

> about the type of surgery she feels best fits her

> particular situation. That procedure is a

> bilipancreatic diversion with duodenal switch

> (BPD/DS), not performed by any physician in plan.

> Below, please find why this particular procedure best

> suits {PATIENT NAME} situation.

>

> 1. Retention of the natural functionality of the

> reduced stomach. The partial " sleeve gastrectomy " is

> unique to this procedure leaving the pyloric valve

> intact and functioning. This means there is no chance

> of post-operative problems that can plague patients

> having the most common form of gastric bypass surgery

> (Roux en Y). These problems being blockages of the

> stoma, marginal ulcerations, narrowing of the

> anastomosis requiring endoscopic dilation, dumping

> syndrome. All of these problems can occur repeatedly

> in RNY patients; not so with BPD/DS patients.

> Furthermore, the BPD/DS stomach is left large enough

> that foods can be properly digested before being

> expelled into the small intestine. This means that

> BPD/DS patients may see greater protein absorption,

> and do see adequate production of intrinsic factor for

> B12 absorption, benefits that are not enjoyed by RNY

> patients.

>

> 2. Retention of the duodenum in the food stream.

> Unlike other forms of gastric bypass, the BPD/DS

> procedure does not completely bypass the duodenum.

> The duodenum is where calcium, iron, protein and zinc

> absorption take place, so BPD/DS patients seldom

> experience the dangerous deficiencies of these

> nutrients. By contract, the RNY procedure completely

> bypasses the duodenum, which seems to compromise

> absorption of these nutrients to a greater degree.

>

>

> This procedure is most effective for patients such as

> {PATIENT NAME}, who are in the super-morbidly obese

> range (BMI higher than 50) and provides the best

> chance at achieving a satisfactory percentage of

> excess weight loss (EWL) for the patient. This

> procedure achieves an average of 80% EWL occurring at

> 24 month post-operative and continues at a 70% level

> for 8 years and beyond. For {PATIENT NAME}, this

> translates to a final weight of ______ lbs – well

> below the " morbidly obese " range. (By contrast, the

> RNY promises only 55% EWL and a final weight of

> ________ lbs. – clearly not a satisfactory result).

> In this case, the BPD/DS procedure is warranted in

> order to give her the best chance to reach a healthy

> weight and reduce or eliminate her co-morbidities and

> to maintain the weight loss for the long term.

>

> {PATIENT NAME} would like to have this procedure

> performed by Rabkin, MD of the Pacific

> Institute of Surgery for Obesity. He is located at:

> Pacific Laparoscopy, 2100 Webster Street Suite 512,

> San Francisco, CA 94115. His phone number is

> .

>

> All of the factors cited above are compelling to the

> patient and myself. As her primary care physician, I

> feel that it is incumbent upon you as her health

> insurer to consider these things and approve our

> request for authorization of services as it is clearly

> in the best interest of her long-term health and

> well-being.

>

>

>

>

> =====

> Dee

> Waiting for Ins. Co. Approval

> 313/Want to be 165

>

> __________________________________________________

>

[Guest guest]

thank you for the feedback. I added a line

about including the report you are writing about.

By the way, thank you so much for preparing and

sharing the report about the 3 types of WLS. You have

saved me (and alot of others, I'm sure) HOURS of work

in putting all of the info together. Thank you!

dee

--- chull1@... wrote:

> Dee,

>

> It is a good letter. My only suggestion is that you

> add the

> appropriate references to the medical literature, as

> it will add

> credability to your statements. You can find

> numerous references and

> information in " Hull's Folder " . In my " Aetna

> Letter " you will

> find over 40 references which you can use.

>

> Hull

>

>

> > Hi, I got this sample letter from another site

> > (obesityhelp.com?). I was going to give this to

> my

> > PCP to use when he sends in the DS rec letter to

> my

> > insurer as they say they won't cover the DS. What

> do

> > you think of the content?

> > _______________________________________

> >

> >

> >

> > RE: {PATIENT NAME}

> > Patient ID {ID #}

> >

> >

> > The above-named is under my care for {LIST

> > CO-MORBIDITIES HERE}. The patient is ___ years

> old,

> > ____ feet ___ inches tall and weighs ______ pounds

> > with a body mass index of ____. Her super-morbid

> > obesity is not being controlled by extreme dietary

> > measures. {PATIENT NAME} is going to pursue

> gastric

> > bypass surgery and we are supportive of her

> decision.

> >

> > {PATIENT NAME} has researched the various methods

> of

> > gastric bypass surgery and has come to a decision

> > about the type of surgery she feels best fits her

> > particular situation. That procedure is a

> > bilipancreatic diversion with duodenal switch

> > (BPD/DS), not performed by any physician in plan.

> > Below, please find why this particular procedure

> best

> > suits {PATIENT NAME} situation.

> >

> > 1. Retention of the natural functionality of the

> > reduced stomach. The partial " sleeve gastrectomy "

> is

> > unique to this procedure leaving the pyloric valve

> > intact and functioning. This means there is no

> chance

> > of post-operative problems that can plague

> patients

> > having the most common form of gastric bypass

> surgery

> > (Roux en Y). These problems being blockages of

> the

> > stoma, marginal ulcerations, narrowing of the

> > anastomosis requiring endoscopic dilation, dumping

> > syndrome. All of these problems can occur

> repeatedly

> > in RNY patients; not so with BPD/DS patients.

> > Furthermore, the BPD/DS stomach is left large

> enough

> > that foods can be properly digested before being

> > expelled into the small intestine. This means

> that

> > BPD/DS patients may see greater protein

> absorption,

> > and do see adequate production of intrinsic factor

> for

> > B12 absorption, benefits that are not enjoyed by

> RNY

> > patients.

> >

> > 2. Retention of the duodenum in the food stream.

> > Unlike other forms of gastric bypass, the BPD/DS

> > procedure does not completely bypass the duodenum.

>

> > The duodenum is where calcium, iron, protein and

> zinc

> > absorption take place, so BPD/DS patients seldom

> > experience the dangerous deficiencies of these

> > nutrients. By contract, the RNY procedure

> completely

> > bypasses the duodenum, which seems to compromise

> > absorption of these nutrients to a greater degree.

> >

> >

> > This procedure is most effective for patients such

> as

> > {PATIENT NAME}, who are in the super-morbidly

> obese

> > range (BMI higher than 50) and provides the best

> > chance at achieving a satisfactory percentage of

> > excess weight loss (EWL) for the patient. This

> > procedure achieves an average of 80% EWL occurring

> at

> > 24 month post-operative and continues at a 70%

> level

> > for 8 years and beyond. For {PATIENT NAME}, this

> > translates to a final weight of ______ lbs – well

> > below the " morbidly obese " range. (By contrast,

> the

> > RNY promises only 55% EWL and a final weight of

> > ________ lbs. – clearly not a satisfactory

> result).

> > In this case, the BPD/DS procedure is warranted in

> > order to give her the best chance to reach a

> healthy

> > weight and reduce or eliminate her co-morbidities

> and

> > to maintain the weight loss for the long term.

> >

> > {PATIENT NAME} would like to have this procedure

> > performed by Rabkin, MD of the Pacific

> > Institute of Surgery for Obesity. He is located

> at:

> > Pacific Laparoscopy, 2100 Webster Street Suite

> 512,

> > San Francisco, CA 94115. His phone number is

> > .

> >

> > All of the factors cited above are compelling to

> the

> > patient and myself. As her primary care

> physician, I

> > feel that it is incumbent upon you as her health

> > insurer to consider these things and approve our

> > request for authorization of services as it is

> clearly

> > in the best interest of her long-term health and

> > well-being.

> >

> >

> >

> >

> > =====

> > Dee

> > Waiting for Ins. Co. Approval

> > 313/Want to be 165

> >

> > __________________________________________________

> >