Does Anyone Have Some Time To Help Me With This Letter?

[hm734 228]

I am hoping someone will have a little extra time to help me with a compelling letter to my insurance company. I will try and give you a little back story to help explain what this is for.

I have been working with my husbands Union Health benefits office for 2 years to get bariatric surgery. They have been very nice, but their plan is somewhat of a PITA as they require 6 months of medically supervised weight loss PLUS a 12 month maintenance period before they cover any visits (consults or otherwise) for WLS. I completed everything and was given the green light. I went to my consult, NUT, in for my single psych eval and submitted all my documentation....Long story short, my Husbands Union uses a third party for bariatric approval and they requested MUCH more testing, more recent documented weight loss attempts, 6 total NUT visits (self paid), 6 psych exams (self paid again), and all kinds of other weird stuff usually done in your pre-ops. After spending much of that day on the phone, the Union has agreed that they would go by my explanation of benefits, and all I needed was a new physical and updated labs.

I will be submitting these tomorrow, however I wanted to include a compelling letter, and quite frankly I am not good at this. Is there anyone here that is good at this kind of thing? I wanted to highlight my co-morbidities and the fact that I am NOT having this surgery for appearance reasons. I am SICK of being SICK. The doctor I saw today (not my usual doctor because he was booked until Sept for well visits) told me that I would be dead by the time I was 50 if I did not get some help. He said he has never seen anyone as small as me have so many health problems (uh, thanks?)

See...I ramble! I need some help writing a short and very sweet letter. Because my first submit was closed instead of denied, I want to get approval and move on with my life without having to appeal.

My current weight is 209.5 pounds and I am 5' 3”. This makes my BMI 37.1.

My health issues include:

Hypertension (despite being treated with Metoprolol)

Crainal Hypertension (causing severe headaches)

Metabolic syndrome

High Cholesterol (despite being treated with Niacin 500mg daily)

Pre-Diabetic (being controlled by Metformin 750mg two times per day)

Urinary stress incontinence (requiring use of a pantyliner all the time, and maxi pad at night)

Polycystic Ovarian Syndrome (despite being treatment of Metformin 750mg two times per day)

GERD (despite being on Nexium)

High Triglycerides (despite treated with Niacin 500mg daily)

Can anyone help?

[Back~To~Amy 307]

I'm a bit confused. Do you need to send a letter or you just want to? I understood your post to say the third pary company would go ahead and cover you with a new physical and updated labs. I'd be glad to help you though! I just don't understand why you need this letter. Are you afraid they aren't going to cover you with what you've already done? Just PM me your email address and a little more details about why you want or need to send this letter so I understand and I'll help you off the boards.

[hm734 228]

Amy,

I will post here in case I confused others as well. My insurance company did not agree to cover my surgery yet, they just agreed to follow the guidelines outlined in my summary plan description instead of the extras the third party was asking for. Does that make more sense? I know it is confusing, I am confused myself!

[notime 340]

Enclosed are the reports of my physical and my lab tests. These are the final items my insurance company requested to support approval of payment for my bariatric surgery.

My doctors have determined that substantial permanent weight loss is necessary to mitigate the current and future cost and quality-of-life effects of my obesity. I would like to remind you of my current health issues, the reason for the necessity of the surgery. They include

--hypertension despite being treated with Metoprolol,

--cranial hypertension which causes me to have severe headaches,

--metabolic syndrome,

--high cholesterol despite being treated with Niacin 500mg daily,

--pre-diabetes currently being controlled by Metformin 750mg two times per day,

-- urinary stress incontinence requiring use of a pantyliner all the time and maxi pad at night,

--polycystic ovarian syndrome despite being treated with Metformin 750mg two times per day,

--GERD despite being treated with Nexium, and

--high triglycerides despite being treated with Niacin 500mg daily

I anxiously await your decision.

[Back~To~Amy 307]

Enclosed are the reports of my physical and my lab tests. These are the final items you requested to support approval of your payment for my bariatric surgery.

My doctors have determined that substantial permanent weight loss is necessary to mitigate the current and future cost and quality-of-life effects of my obesity. I would like to remind you of my current health issues' date=' the reason for the necessity of the surgery. They include

--hypertension despite being treated with Metoprolol

--cranial hypertension which causes me to have severe headaches;

--metabolic syndrome

--high cholesterol despite being treated with Niacin 500mg daily;

--pre-diabetes currently being controlled by Metformin 750mg two times per day

-- urinary stress incontinence requiring use of a pantyliner all the time and maxi pad at night

--polycystic ovarian syndrome despite being treated with Metformin 750mg two times per day

--GERD despite being treated with Nexium

--high triglycerides despite being treated with Niacin 500mg daily

I anxiously await your decision.[/quote']

This is good. You might just include a statement about how they agreed to make their determination on the requirement Ta the insurance company advised you of and not the additional things they told you.

Also, I responded to your PM.

[notime 340]

I made some edits to my post.

[hm734 228]

Thank you to both Amy and notime! I will get this into a letter, add a little personal info and send it off. I will let you know as soon as I hear something!

[hm734 228]

OMG!!!! I am SO FRIGGEN EXCITED! I just got a call.....

I HAVE BEEN APPROVED! My husbands Union re-opened my case and called my surgeons office with the approval and pre-auth code. I call Monday morning to get my surgery date. THANK YOU notime and Amy for helping me get this letter out. I did some tweaking and made it quite a bit more personal and apparently it worked. You guys rock!.

I feel like I won the lottery!! YAHOOOOOOOOOOO!

[notime 340]

Congratulations!

[Almostthere34 128]

Love this forum! :-)

[Back~To~Amy 307]

That is great to hear! Congrats!