LETTER OF MEDICAL NECESSITY â€“ SAMPLE
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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.