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Read my "letter of medical necc" and tell me if I have a chance



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Hi, here is the letter my PCP sent to Cigna. Do you think it is compelling/informational/persuasive enough to get the sugery covered? Is this close to what your letter looked like?

I am writing this letter of medical necessity on behalf of my patient, xxxxx. I am requesting insurance coverage for a laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric band (gastric band and subcutaneous port components) and the CPT code is 43770. She has tried numerous diets and weight loss programs for the last 15 years. She is successful for a few months but her weight loss was 5% or less and short-lived. She has gained the weight back and more time and time again. She had a resting metabolic rate done in our office in August 2005 and had consequently followed the caloric recommendations with daily exercise and gained 5lbs over the next six months. Her BMI was 39.5 in February 2006.

Here are some of her weight loss attempts:

In the last 5 years she has tried the following diets (with exercise):

Weight Watchers (multiple attempts)

South Beach

Low-carb (Atkins)

Low-calorie, low-fat calorie counting.

EXERCISE:

She also has been seeing a personal trainer for 9 months.

She was on a diet of 1700 calories a day for 4 months.

In all of these attempts her weight loss was 5% or less and short-lived.

Weight related conditions:

Swelling of feet and legs, knee pain, achy joints, and pain in arches and heels if she is on her feet for any length of time. She has low back pain after only 15 or 20 minutes of walking or standing. She has tried better shoes and supports but to no avail.

She has been diagnosed with depression and anxiety. Her medications include Zoloft and Wellbutrin. She suffers emotionally from being overweight.

Family history in her words:

3 of my 4 grandparents died of heart disease. My mother, father and brother are obese. My uncle is taking medication for high blood pressure and high cholesterol.

I will enclose her recent office visits and tests that have been performed since she has been under my care.

Please fax or email me with decision of patient's coverage for surgery. If I can provide any other information please let me know.

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Sounds good to me. Hang in there and good luck!!:confused:

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    • Alisa_S

      On day 4 of the 2 week liquid pre-op diet. Surgery scheduled for June 11th.
      Soooo I am coming to a realization
      of something and I'm not sure what to do about it. For years the only thing I've enjoyed is eating. We rarely do anything or go anywhere and if we do it always includes food. Family comes over? Big family dinner! Go camping? Food! Take a short ride or trip? Food! Holiday? Food! Go out of town for a Dr appointment? Food! When we go to a new town we don't look for any attractions, we look for restaurants we haven't been to. Heck, I look forward to getting off work because that means it's almost supper time. Now that I'm drinking these pre-op shakes for breakfast, lunch, and supper I have nothing to look forward to.  And once I have surgery on June 11th it'll be more of the same shakes. Even after pureed stage, soft food stage, and finally regular food stage, it's going to be a drastic change for the rest of my life. I'm giving up the one thing that really brings me joy. Eating. How do you cope with that? What do you do to fill that void? Wow. Now I'm sad.
      · 1 reply
      1. LeighaTR

        I hope your surgery on Wednesday goes well. You will be able to do all sorts of new things as you find your new normal after surgery. I don't know this from experience yet, but I am seeing a lot of positive things from people who have had it done. Best of luck!

    • Alisa_S

      On day 4 of the 2 week liquid pre-op diet. Surgery scheduled for June 11th.
      Soooo I am coming to a realization
      of something and I'm not sure what to do about it. For years the only thing I've enjoyed is eating. We rarely do anything or go anywhere and if we do it always includes food. Family comes over? Big family dinner! Go camping? Food! Take a short ride or trip? Food! Holiday? Food! Go out of town for a Dr appointment? Food! When we go to a new town we don't look for any attractions, we look for restaurants we haven't been to. Heck, I look forward to getting off work because that means it's almost supper time. Now that I'm drinking these pre-op shakes for breakfast, lunch, and supper I have nothing to look forward to.  And once I have surgery on June 11th it'll be more of the same shakes. Even after pureed stage, soft food stage, and finally regular food stage, it's going to be a drastic change for the rest of my life. I'm giving up the one thing that really brings me joy. Eating. How do you cope with that? What do you do to fill that void? Wow. Now I'm sad.
      · 1 reply
      1. summerseeker

        Life as a big person had limited my life to what I knew I could manage to do each day. That was eat. I hadn't anything else to look forward to. So my eating choices were the best I could dream up. I planned the cooking in managable lots in my head and filled my day with and around it.

        Now I have a whole new big, bigger, biggest, best days ever. I am out there with those skinny people doing stuff i could never have dreamt of. Food is now an after thought. It doesn't consume my day. I still enjoy the good home cooked food but I eat smaller portions. I leave food on my plate when I am full. I can no longer hear my mother's voice saying eat it all up, ther are starving children in Africa who would want that!

        I still cook for family feasts, I love cooking. I still do holidays but I have changed from the All inclusive drinking and eating everything everyday kind to Self catering accommodation. This gives me the choice of cooking or eating out as I choose. I rarely drink anymore as I usually travel alone now and I feel I need to keep aware of my surroundings.

        I don't know at what point my life expanded, was it when I lost 100 pounds? Was it when I left my walking stick at home ? Was it when I said yes to an outing instead of finding an excuse to stay home ? i look back at my last five years and wonder how loosing weight has made such a difference. Be ready to amaze yourself.

        BTW, the liquid diet sucks, one more day and you are over the worst. You can do it.

    • CaseyP1011

      Officially here for a long time, not just a good time💪
      · 0 replies
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