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DATE
INSURANCE COMPANY
ADDRESS
CITY,STATE,ZIP
YOUR NAME
YOUR INSURANCE IDENTIFACATION NUMBER
YOUR GROUP NUMBER
Dear (INSURANCE COMPANY NAME),
I am writing to seek Pre-Authorization for Laparoscopic Adjustable Gastric Band surgery. The CPT code for this procedure is 43659. As you read through this letter you will find that this surgery is not an attempt to better my looks but that it is medically necessary. I believe that the Laparoscopic Adjustable Gastric Band is the safest way for me to be able to have a healthy and happy life, and it will save you the costs of medical bills that will almost definitely go along with my obesity over the years.
As of the day I wrote this letter I stand (HEIGHT), and have a weight of (INSERT WEIGHT), giving me a Body Mass Index of (INSERT BMI). Under guidelines issued by the National Institute of Health I suffer from the disease of morbid obesity (ICD-9 code 278.01). The 1991 NIH Consensus Conference convened to study weight loss surgery and determined that surgery is appropriate in persons such as myself who have a BMI greater than 40 or a BMI over 35 when serious co-morbid medical conditions are present , or because a persons weight interferes with normal life activities. I suffer from numerous medical conditions that could be improved with weight loss; these are (INSERT ANY MEDICAL CONDITIONS YOU SUFFER FROM OR ANY PROBLEMS AGGREVATED BY YOUR WEIGHT.)
These Problems are serious and potentially life threatening.
Over the years I have tried many diet and exercise plans. (INSERT DIETS YOU HAVE TRIED, EXERCISE PLANS, WEIGHTLOSS DRUGS, EXERCISE EQUIPMENT YOU HAVE PURCHASED, PHYSICIANS WHO HAVE TALKED TO YOU ABOUT WEIGHT LOSS, ANYTHING YOU HAVE TRIED !!!! BE SPECIFIC, DATES LENGTH OF TIME YOU TRIED ANYTHING AND COST TO YOU!!!)
I want to make sure that I am around for many years to come to be a benefit and not a burden on my family. My family has a medical history of (INSERT ANY MEDICAL PROBLEMS WITHIN YOUR FAMILY UNIT).
I have reviewed the extensive literature on the Lap-Band system and have concluded that this is the best choice for me. It is less invasive, adjustable, and reversible versus other Bariatric surgeries. Since there is no bypass or stapling of my intestines the risk of serious complications is minimized.
I believe that this procedure is the safest way for me to lose weight and that having this procedure can lengthen and improve life as I know it. Please approve me to have a Laparoscopic Adjustable Gastric Band placed.
Sincerely,
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