Sample Letter Requesting Insurance Coverage and ... - Ethicon

[Date]
[Contact]
Sample Letter Requesting Insurance Coverage and Authorization for
[Insurance Company Name]
[Address]
[City, State Zip Code]
Hospitalization and Surgical Treatment for Morbid Obesity
Patient Name: [Insert patient name.]
Policy Number: [Insert policy number.]
Group Number: [Insert group number.]
Diagnosis: [Insert diagnosis and ICD-9-CM code(s).]
Dear [name or contact]:
I am writing on behalf of my patient, [patient name], to request coverage and appropriate payment
for [Laparoscopic Adjustable Gastric Banding (LAGB)/Gastric Bypass (GB)/Sleeve Gastrectomy]. This letter provides
information on the patient’s diagnosis and treatment, as well as product literature demonstrating
medical necessity for the [LAGB/GB/Sleeve Gastrectomy] and associated procedures.
Predetermination/certification of insurance coverage, and authorization for hospitalization and
surgical treatment, are requested on behalf of [patient name] for diagnoses of [can include as applicable,
examples: hypertension (401.1), diabetes mellitus (250.00), GERD (530.81), heartburn (787.1), sleep apnea (780.57), arthralgias of
weight bearing joints (719.49)]. The patient’s general condition, suffering from multiple diagnoses, is
complicating the underlying clinically severe morbid obesity (278.01).
The conditions typically improve and may disappear with weight loss.
Page 1 of 3 © 2012 Ethicon Endo-Surgery, Inc. All rights reserved. DSL: 12-0352.LR

I am requesting authorization for [LAGB/GB/Sleeve Gastrectomy]. (Insert relevant CPT surgical code and description;
e.g., 43770 – Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric band (gastric band and
subcutaneous port components)) to be performed for the treatment of the patient’s severe and lifethreatening
diseases. The procedure will be performed at [hospital/facility name]. Without this
procedure, it is my opinion that significant problems could develop that will result in future
costly hospitalization(s).
[Provide description of LAGB/GB/Sleeve Gastrectomy procedure here]
This individual is [height], weighs [weight], and has a Body Mass Index of [insert BMI here]. [He/She] has
been severely obese for a number of years despite many years of dietary efforts, including the
use of dietary programs such as [provide complete history of tried and failed weight loss management treatment and
programs]. [He/She] has lost weight greater than [XX] pounds [XX] times; [he/she] has been unable to
achieve a healthful body by dietary restrictions. As pointed out in the NIH Consensus Panel, it is
very unlikely that [he/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 nonsurgical
methods, 90 to 95 percent of people who lose weight subsequently regain it 1, 2 . It is also well
documented that there is a significant increase in mortality as the Body Mass Index exceeds
32kg/m 2 . An editorial in the New England Journal of Medicine 3 states, “studies provide
additional evidence to strengthen the already compelling conclusion that extreme obesity
shortens lives.” Studies also show a substantial increase in risk of diabetes with even a modest
weight gain. This is truly a morbid and life-threatening disease.
These conditions predictably will, along with other problems that characteristically appear,
become increasingly incapacitating in the absence of significant weight loss. Because medical
management has failed to produce and maintain weight loss for this patient, I strongly believe
bariatric surgery is necessary in order to successfully resolve or ameliorate the multiple medical
problems associated with [his/her] morbid obesity (278.01).
Page 2 of 3 © 2012 Ethicon Endo-Surgery, Inc. All rights reserved. DSL: 12-0352.LR

As I have reviewed all options with the patient through informed consent, [he/she] has good
understanding of the [LAGB/GB/Sleeve Gastrectomy] procedure and its risks and complications, and has
determined that [LAGB/GB/Sleeve Gastrectomy] is the best option for [him/her]. Additionally,
[he/she] has agreed to monthly support group meetings for at least one year postoperatively.
I most strongly request that you clear your annuitant for coverage. [His/Her] diseases are
progressive and life threatening. I am asking for an efficient and timely review of this case. I am
requesting from you in writing a pre-authorization for inpatient surgery.
Sincerely,
[Physician name]
1
Wadden TA. Treatment of obesity by moderate and severe caloric restriction: results of clinical research trials. Ann Intern Med
1993;229:688-693.
2
Rosenbaum M, Leibel RL. Pathophysiology of Childhood Obesity. Adv. Pediatr 1988;35:73-137.
3
Byers T. Editorial: Body Weight and Mortality. NEJM 1995;333:723-724.
Page 3 of 3 © 2012 Ethicon Endo-Surgery, Inc. All rights reserved. DSL: 12-0352.LR