Need Help - no secondary condition
 

I am just starting the process for Lap-band surgery and step 1 is to get approval from the insurance company. Because if insurance won't pay, I can't have it.

I called today and I have to mail in a Letter of Medical Necessity. I need to include...

1. Height
2. Weight
3. Time I have been at this weight
4. Any secondary conditions
5. Any diet programs I have tried in the past

She stressed that to get approval you need to be morbidly obese (check) and you need to have a serious secondary condition. That's my problem. I really don't have a serious secondary condition. I do have elevated cholesteral, but it's not very high. I have leg cramps but that's it. :( Any ideas on how to approach this?? I am hoping that because my weight is sooo high that that will help will approval, but lacking the secondary condition makes me worry.

Any tips on this letter - things to include or not include??

Hi Sandi,

My surgeon's office was very thorough in helping me find other conditions. They pointed things out to me that I wasn't even aware would qualify as secondary conditions. For instance, they listed stress incontinence as a problem (very small for me, but it was a condition), and they found I was pre-diabetic (which I was totally unaware of). I can't remember all the others, but it was kind of amazing.

I prepared a chart detailing all the diets I'd tried with the dates and results and they found it very helpful. I'm not sure who your insured with, but United Healthcare was fairly easy to deal with once they had the facts in their hot little hands.

Good Luck,
Chickadee

I made an appointment with my GP - should I be meeting with a surgeon instead and having him send out the letter???

a Doctor at the hospital I had Gastric bypass at did the letter for me. Your surgeon should be able to direct you to lap band friendly docs if your GP isn't supportive

I think my GP will be supportive, but I have to wonder if he is the best person to write the letter.

It all depends on your insurance. First step is to call your insurance to make sure they cover the band. I did not need a letter from my GP, but my GP did have to give me a physical for the insurance company.

Ususally the surgeon writes the letter to the insurance company and they can/will come up with things to help you.

What insurance do you have?

The insurance company is the one who said I needed to mail in a letter. I guess I'll stick with my GP and see what he says on Monday. Maybe he'll have some ideas. He knows of any problems I have had.

How do you find a surgeon?

Sandi - babe- darlin - wow. lots of movement here. i think finding a surgeon should be a major priority right now. does your insurance company have a list of surgeons in their plan? lots of surgeons in around the country are out of network - and that might be an issue for you.

as for finding a surgeon, here are some key things to check

1. is the surgeon ASBS certified?
2. what's the support group like?
3. what kind of other health care professionals are involved in the program? what's their role?
4. how much experience does the hospital have with these surgeries?
5. how convenient is the surgeon - you'll have to go regularly for adjustments

now, having said ALL THAT, letters to insurance companies generally come from the surgeon - the GP may offer support, but the surgeon generally has it all down to a science.

My GP researched and recommended me to my surgeon but he is one in a million! The key is find a Dr. that is experienced with the lapband and especially has a good aftercare program as fills and followups are critical to your long-term success.

As for secondary conditions, one of the "biggies" is sleep apnea which a lot of MO people suffer from - have you ever been tested? Any decent surgeon will require it as one of your pre-op tests so if your GP will order it then that might serve as a good co-morbidity. I just looked through my info packet and found the initial survey they had me fill out. Here is the list of obesity-related conditions they asked about:
- diabetes
- high blood pressure
- high cholesterol
- low back pain
- arthritis/joint pain
- asthma
- history of gastrointestinal (acid) reflux
- sleep apnea
- urinary incontinence
- depression

Good Luck,

I was very concerned about a secondary condition as well. Because I didnt have any common conditions for morbid obesity or so I thought. I did have major depression though. My insurance did cover my surgery and I thought it was no way they would except that, but God worked it out for me. Good Luck to you!