Here are copies of the letters I used
My letter from my PCP:
Texas
Rehabilitation Commission
1015
Jackson Keller, Suite 103
San
Antonio, Texas 78213
(210)
349-2684 Fax: (210) 349-3944
Dear Mr. (Counselor's Name),
This letter is regarding Mr. Douglas L. Heyde, who is a
patient of mine seeking the Roux-En-Y Gastric Bypass. Mr. Heyde is more
than twice his ideal body weight, which puts him well within range for the
diagnosis of Morbid Obesity. He also has several co-morbidities, which are
exacerbated by his weight,. The patient is 5'11", weighing 515 lbs and has
a body mass index (BMI) of 70.
The patient displays the following co-morbidities which gastric bypass surgery
and the resulting weight loss has been proven to alleviate:
Type
II Diabetes
Hypertension
Sleep
Apnea
Chronic
back, hip, and knee pain
Despite numerous diet attempts, since the age of 8, Mr. Heyde has never been
able to maintain a healthy weight. These methods include prescription
medication intended to support weight loss such as Xenical and Prozac, seeing a
Nutritionist, over-the-counter weight loss/appetite suppressants, Weight
Watchers, Nutri-System, and numerous other diet attempts. Mr. Heyde has lost
weight on these methods, and then regained the weight, with additional pounds.
Due to the patient’s diet history and serious health concerns, I do not
consider him a candidate for currently approved weight loss medications. In
addition, weight loss surgery is by far the most effective long-term treatment
for patients with morbid obesity.
I consider this patient a good candidate for gastric bypass.
My referral to Dr. Dana Reiss who perfoms this surgery was refused by Mr.
Heyde’s insurance company. I believe, not only would surgery improve, and in
some cases totally remove, his co-morbidities, it would most probably
extend Mr. Heyde’s life. I am therefore, strongly recommending the
approval of his case, so he may receive the RNY Gastric Bypass, as soon as
possible.
Sincerely,
Dr.
(Your Doctor's Name)
Primary
Cary Physician
My letter from my Pulmonologist:
Texas
Rehabilitation Commission
1015
Jackson Keller, Suite 103
San
Antonio, Texas 78213
(210)
349-2684 Fax: (210) 349-3944
Mr. (Put your Counselor's Name Here),
This letter is in support of my patient
Douglas
L. Heyde
123-45-6789
11/11/11
receiving Gastric Bypass surgery. I
treat Mr. Heyde for sleep apnea, a life-threatening condition often caused by
obesity in which the patient stops breathing during sleep. This condition causes sufferers to sleep poorly which often
results in drowsiness and inattentiveness during the day. This can significantly
impede performance on the job and in daily life situations, such as driving a
car.
In the initial sleep study performed by my
staff, Mr. Heyde stopped breathing an average of 60 times an hour.
To treat this condition, the patient uses a CPAP machine every time he
sleeps. This device merely assists
Mr. Heyde in breathing, it does nothing to cure sleep apnea.
I strongly recommend weight loss surgery
for Mr. Heyde. Losing weight would
in all likelihood alleviate his sleep apnea.
Sincerely,
(Your Doctor's Name Here)
My Endocrinologists letter
May 7, 2002
Texas
Rehabilitation Commission
1015
Jackson Keller, Suite 103
San
Antonio, Texas 78213
(210)
349-2684 Fax: (210) 349-3944
Re:
Douglas L. Heyde
D.O.B.
11/11/11
SSN
123-45-6789
Dear
Mr. (counselor's name),
I
am writing this letter on behalf, of my patient, Douglas L. Heyde, who is
currently seeking coverage of the Roux-En-Y Gastric Bypass.
I have prescribed Xenical for him which failed to provide enough weight
loss to positively impact his health. Mr.
Heyde participated in the education program affiliated with my practice which
included a nutrition/diet plan developed specifically for him.
Even when he has been successful in losing weight, he has been unable to
keep the weight from returning.
Mr.
Heyde has several health issues which are negatively impacted by his weight.
I have been treating him for Type II diabetes and hypertension for
several years. He takes several medications as well as daily insulin
injections to control these problems. It
is my opinion that Mr. Heyde’s current medical conditions would be vastly
improved by the loss of the bulk of his excess weight. Surgical treatment
is medically necessary because it is the only proven method of achieving long
term weight loss for the morbidly obese.
Sincerely,
Dr.
(Your Doctor's Name Here)