LETTER OF MEDICAL NECESSITY – SAMPLE

							                      LETTER OF MEDICAL NECESSITY – SAMPLE


To Whom It May Concern:

Certification of insurance coverage, and authorization for hospitalization and surgical treatment
are requested on behalf of the above referenced beneficiary, for the diagnoses of Arthritic
Symptoms of the Weight Bearing Joints (716.98), Gastro-Esophageal Reflux Disease (530.81),
Stress Incontinence (626.6), Heart Disease (785.2), Hypercholesterolemia (272.00),
Hypertriglyceridemia (272.1), Asthma (493.90), Essential Hypertension (401.9), Diabetes
(250.00), and Sleep Apnea (780.57). The patient’s general condition, suffering from multiple
diagnoses, is complicating the underlying clinically severe obesity or Morbid Obesity (ICD-9
278.01).

The patient is a 44 –year old female whose body weight is 254 pounds and whose height is 71
inches. The calculated body mass index is 51.10 kg/m2. The patient has been dieting since the
age of 20. She has tried several dietary regimens including Jenny Craig in 1990 fro six months,
Weight Watchers in 1998 for several months with a 28 –pound weight loss. She also tried liquid
protein diet in 1997 for six months, but most often she has tried self-regimented diets several
times with a moderate amount of weight loss, from 20 –30 pounds; but her most important
problem seems to be the inability to keep the weight off. As pointed out in the NIH Consensus
Panel, it is very unlikely that she could accomplish this goal in the future. The scientific facts are
that despite years of treatments directed toward long –term reduction of body weight by non –
surgical methods, 90 to 95 percent of persons who lose weight subsequently regain it. It is also
well documented that there is a significant increase in mortality as the body mass index excesses
32 kg/m2. An editorial in the New England Journal of Medicine states, “studies provide
additional evidence to strengthen the already compelling conclusion that extreme obesity
shortens lives”. Studies also show a substantial increase in the risk of diabetes with even the
modest most modest weight gain. This is truly a morbid and life –threatening disease.

Let me be somewhat more specific about the patient’s major diagnoses. These are individual
ICD-9 coded diagnoses, however, they are also co-morbidities of the patient’s global health risk.
While defining these individual disease states, we will supply literature to support that the best
treatment of each individual diagnosis is bariatric surgery and therefore the patient’s best hope is
through this type of intervention. We are specifically not requesting authorization for the
treatment of Obesity, but rather for the treatment of MORBID OBESITY. These are different
diseases clinically and as defined by the ICD-9 codification. If your company’s benefits package
excludes the treatment of “obesity” (i.e., dietary planning or behavior modification), therefore,
do not confuse the two diseases and deny benefits inappropriately!

Arthritic Symptoms of the Weight Bearing Joints (ICD-9 code 716.98) are protean in the
morbidly obese population. Many have changes severe enough to require joint replacement due
to the joint destruction. Many others with severe symptoms can avoid joint replacement surgery
with weight reduction. Joint replacement surgery is not as safe nor is as successful in morbidly
obese individuals. Studies show the replacement joints wear out sooner in obese patients and
weight loss is not induced by more exercise capability after joint replacement. As surgically
induced weight loss is most effective (both in terms of pounds lost and in terms of long-term
maintenance of weight loss) it is the best therapy suited for the patient’s orthopedic problems.
The patient has a significant amount of low back pain as well as pain specifically in her right hip
compared to the other weight bearing joints. She had cortisone injections in the right hip with a
brief period of relief, but she continues to have problems with her hip.

Gastro-Esophageal Reflux Disease (ICD-9 code 530.81) not only causes a major alteration in
one’s lifestyle, but can also lead to stricture, dysphasia, aspiration, and asthma. In certain
instances, it can lead to the development of cancer. The medication used for the treatment of this
disease is quite costly and may not protect the patient from the side effects even though the
symptoms may be controlled. Bariatric surgery is quite effective in controlling the symptoms
and recent studies indicate it may reverse the pre-malignant changes in the esophagus.
Healthcare plans have realized it is more cost effective to perform an anti-reflux operation than
to pay for years of expensive medications and the cost of repeated endoscopies and the treatment
of the associated complications. Our data (confirming other papers in the bariatric literature)
shows essentially complete resolution of the process with a laparoscopic procedure. The patient
has had significant heartburn for approximately 12 years. She has been on different medication
for about the last eight or nine years including Pepcid and Zantac, but more recently in the last
four years she has been using Prevacid 30 mg once a day. With the Prevacid on a regular basis,
she has been asymptomatic. She says she had a peptic ulcer disease as a child, but it has gotten
better.

Stress Incontinence (ICD-9 code 625.6) A large heavy abdomen and relaxation of the pelvic
muscles, especially associated with the effects of childbirth, may cause the valve on the urinary
bladder to be weakened, leading to leakage of urine with coughing, sneezing, or laughing. The
patient has stress incontinence especially when coughing.

Hypercholesterolemia (ICD-9 code 272.00), Hypertriglyceridemia (ICD-9 code 272.10) The
patient has high cholesterol and high triglycerides diagnosed in the year 2000. Her primary care
physician started her on Zocar. Currently, she takes Zocar on a very regular basis with a regular
follow-up and apparently her numbers have improved.

Asthma (ICD-9 code 793.90) The patient was diagnosed with asthma in 1994. She is not known
to have asthma as a child. Her asthma seemed to be more related to seasonal changes in spring
and fall, however, her asthma appeared to be fairly severe. She used steroids in March of 2002
for about 30 or 40 days and had been on nebulizer treatments. Currently she takes Advair on a
regular basis. She was hospitalized with asthma in 1999.

Essential Hypertension (ICD-9 code 401.9) The patient does have clinical hypertension that
was diagnosed in 1985 and since that time she has been on many medications. However, she
thinks that she had hypertension before that, but it was not high enough to have been started on
medication. Currently, she takes two medications for her hypertension

Heart Disease (ICD-9 code 785.2) In 1994 the patient was noted to have a heart murmur by her
primary care physician and apparently recently it has changed in character and therefore, she is
due to see a cardiologist. She does not have any chest pains, palpitations, or any other symptoms
associated with heart disease.

Diabetes (ICD-9 code 250.00) The patient has Diabetes Mellitus, which as diagnosed in the year
2001, and it is currently controlled with three different medications. She takes Starlix,
Glucophage, and Avandia every single day; and she takes her blood sugar level twice a day. Her
fasting blood sugar averages to about 114. She does not appear to have any specific
complications related to diabetes.

Sleep Apnea (ICD-9 code 780.57) The patient does have clinical signs and symptoms of
obstructive sleep apnea, including morning headaches, daytime drowsiness, restless sleep,
frequent awakenings at night and snoring. She has not had a sleep study performed and
therefore, we will have her schedule one.

We are requesting authorization for a Laparoscopic Gastric Banding (43770) to be performed for
the treatment of the patient’s severe and life threatening disease of Morbid Obesity, as well as
the other diagnoses listed. A traditional laparotomy will be performed in the event that the
laparoscopic approach is unsuccessful.

We appreciate your consideration in this matter and your timely response.