Sample Letter for Denials - Need Opinions Please

[Guest guest]

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

__________________________________________________