Letter of Medical Necessity (Metabolic/Bariatric Surgery)

Letter of Medical Necessity – Metabolic/Bariatric Surgery Prior Authorization

Date: [Date]
From: [Clinician full name], [Credentials], [Specialty]; NPI: [NPI]
Practice/Facility: [Practice or facility name], [Address]
UM Direct Contact: Phone: [Direct phone] | Fax: [Direct fax]
To: [Payer name], Utilization Management Department; Fax/Portal: [UM fax or portal reference]
Patient: [Full name], DOB: [DOB], Member/Policy ID: [Member ID], Group #: [Group number]
RE: [Procedure name] ([laparoscopic / robotic / open]); DOS: [Planned date / TBD upon authorization]; Facility: [Facility name]
Diagnosis: [Primary diagnosis, ICD-10 code]; CPT: [CPT code]; PA Reference: [PA number if initiated]

Statement of Medical Necessity

[One-sentence request naming procedure, patient name, obesity classification, key comorbidities, and stating documented unsuccessful medical management]

• Anthropometrics: Height [height]; Weight [current weight]; BMI [current BMI] (measured [date], [source])
• Highest documented BMI: [Highest BMI] at [weight] (measured [date], [source])
• Obesity-related comorbidities: [Comorbidities ordered by clinical impact with key objective markers and dates]
• Prior medical management: [Summary of structured programs and/or pharmacotherapy with dates, duration, and outcomes]
• Multidisciplinary evaluation: [Completed evaluations with dates]
• Requested procedure & rationale: [Procedure name and approach] indicated due to [brief rationale]

Request: Authorization for [inpatient / outpatient / 23-hour observation] [laparoscopic / robotic / open] [procedure name] at [facility] on [planned date / TBD upon authorization].

Clinical Background

[Patient name] has [class II / class III] obesity, a chronic progressive disease, with current BMI of [BMI] measured [date].

Date	Weight	BMI	Source	Notes
[Current date]	[Current weight]	[Current BMI]	[Clinic scale / program visit / PCP visit]	[Current clinical context]
[Date of highest weight]	[Highest weight]	[Highest BMI]	[Source]	[Context]
[Additional weight data points from supervised programs and pharmacotherapy trials, including start/end weights with dates and outcomes]

(Include current measurement, highest documented weight/BMI, and start/end weights for each supervised program and pharmacotherapy trial. Label patient-reported values as such. Do not imply continuous monitoring if not documented.)

Obesity-Related Comorbidities

Condition	Evidence of Diagnosis/Severity	Current Therapy	Current Impact	Anticipated Surgical Benefit
[Comorbidity name]	[Objective evidence with dates: lab values, study results, imaging findings]	[Medications/devices with start dates]	[Current clinical impact]	[Expected improvement]
[Additional comorbidities as applicable, ordered by clinical severity and payer relevance]

(Include only diagnoses supported by objective documentation. For suspected but unconfirmed conditions, label as "suspected based on [reason]; evaluation pending" and do not use to meet coverage criteria.)

Prior Medical Management

Structured Weight Management Programs

[Program type], [start date] to [end date] ([duration in months]), [visit frequency], addressing [nutrition / physical activity / behavioral modification]. Outcome: [Weight/BMI change and durability].

Date	Weight	BMI	Clinician Type	Counseling Topics
[Visit date]	[Weight]	[BMI]	[MD / APP / RD / Behavioral Health]	[Topics addressed]
[Additional visits as required by payer]

(Include visit log if payer requires supervised program documentation. Label external program records as patient-reported and note if records are attached.)

Anti-Obesity Pharmacotherapy

• [Medication name]: [Start date] to [end date / ongoing], max dose [dose], response [weight change over timeframe], [adverse effects / contraindications / reason discontinued if applicable]
• [Additional medications as applicable; for GLP-1/GIP agonists, include duration, max tolerated dose, response, and reason for discontinuation]

(If pharmacotherapy was not indicated, state contraindication or clinical rationale.)

Synthesis: Despite appropriate intensity and duration of nonsurgical therapy, the patient has not achieved substantial or durable weight reduction, and obesity-related comorbidities remain clinically significant.

Multidisciplinary Evaluation and Surgical Candidacy

• Bariatric surgeon evaluation: [Date]; [Clearance status]
• Nutrition/dietitian evaluation: [Date]; [Education completed]
• Behavioral health evaluation: [Date]; [Clearance status] (if required by payer)
• Medical clearance: [Date]; [Clearance status and risk stratification]
• Tobacco/nicotine status: [Never / Former / Current]; [Cessation date and verification if applicable]
• Patient education: Informed regarding lifelong follow-up, nutritional supplementation, and adherence requirements; follow-up plan established

(Reference attached clearance documents rather than duplicating detailed findings here.)

Requested Procedure and Rationale

[Procedure name] via [laparoscopic / robotic / open] approach is requested. This procedure is indicated based on [degree of weight loss needed], [specific comorbidity considerations], and [patient factors including prior surgical history and risk profile]. [Alternative procedures / continued medical management alone] [is/are] not optimal because [patient-specific reasons].

Expected Benefits

• [Comorbidity]: [Specific improvement goal]
• [Comorbidity]: [Specific improvement goal]
• Reduced risk of future cardiometabolic complications
• Improved functional status and quality of life: [Specific goals if documented]

(If documented clinical deterioration makes delay harmful, briefly state: "Delaying surgery increases risk due to [objective finding] observed on [date]." Include only if grounded in documented severity.)

Coverage Criteria Crosswalk

Criterion	Evidence (Data, Date, Source/Attachment)
BMI threshold met	[Current BMI, date; highest BMI, date] – Clinical Background; Attachment [#]
Qualifying comorbidity/comorbidities	[Comorbidity with objective evidence and date] – Comorbidities table; Attachment [#]
Documented unsuccessful medical treatment	[Program/pharmacotherapy summary with dates and outcomes] – Prior Medical Management; Attachment [#]
Supervised program requirements	[Duration, visit count, dates] – Visit log; Attachment [#]
Psychological evaluation	[Date, clearance status] – Attachment [#]
Nutrition evaluation	[Date] – Attachment [#]
Medical/surgical clearance	[Date, clearance status] – Attachment [#]
Tobacco abstinence (if required)	[Status and verification date] – Attachment [#]
[Additional payer-specific criteria]	[Evidence and attachment reference]

(If patient meets ASMBS/IFSO 2022 guidelines but payer policy differs, note guideline alignment and request medical director review with brief rationale.)

Attachments Index

1. [Bariatric surgery consultation note] – [Date] (Key pages: [page numbers])
2. [Nutrition evaluation] – [Date]
3. [Behavioral health/psychological evaluation] – [Date]
4. [Supervised weight management visit log] – [Date range]
5. [Laboratory results] – [Date range]
6. [Sleep study report] – [Date]
7. [Additional supporting documents as applicable]

(Include only documents necessary to substantiate coverage criteria. Reference attachment numbers in the crosswalk above.)

Closing

I attest that the information provided is accurate and derived from the medical record and/or clearly labeled patient report. Based on the clinical evidence presented, metabolic/bariatric surgery is medically necessary for this patient, and the expected benefits outweigh the risks. I respectfully request approval of this prior authorization.

For questions or to arrange a peer-to-peer review, please contact me at [direct phone] or [secure email].

Sincerely,
[Clinician name], [Credentials]
[Title], [Practice/Facility]
NPI: [NPI]
Signature: ___________________________

Confidentiality Notice: This letter contains protected health information intended solely for the named recipient(s). If received in error, please notify the sender immediately and destroy all copies.