Sample Letter 1 regarding medically necessary treatment: Download this letter as Word Document
8 June 2007
To Whom It May Concern
RE: XXXXX YYYYY
To Whom It May Concern:
I’ve helped care for XXXXX YYYYY for medically dangerous anorexia nervosa. I first met Ms. YYYYY in the summer of 2006. At that time she had a long history of major depression and a more recent history of critical weight loss (100 pounds to < 80 pounds). She had just completed a 10-day inpatient hospitalization for weight loss and depression yet was still unable to manage any meaningful increase in her eating or weight. At our initial evaluation, XXXXX was cachectic-appearing. Her examination was notable for a height of 153.5 cm and a weight of 34.3 kg. I calculated her body mass index to be 14.5 and more than 4 standard deviations below the mean for BMI. Weight was at 65% of ideal body weight, pulse 50’s, and blood pressure 103/62. An EKG demonstrated sinus bradycardia at a rate of 55 the PR, QRS, and QTc intervals were within normal limits. Nonspecific T-wave changes were seen. Laboratory studies revealed normal electrolytes, normal renal function, and a glucose of 75. AST and ALT were elevated (37 and 36). TSH was 0.44, magnesium 2.2, phosphorus 4.3.
My impression at our first visit was that XXXXX had long-standing major depression and had more recently developed anorexia nervosa. She was dramatically malnourished and cachectic appearing and had physical symptoms and signs related to her malnutrition. Though XXXXX had made some efforts at trying to improve her intake; these had been largely unsuccessful. Her weight at my initial visit was, by her report, her lowest weight. We restricted XXXXX from any physical activity. We discussed with XXXXX the importance of significantly increasing her food intake and talked about specific strategies for doing so. We discussed that if she was not able to do so in the short term, then hospitalization will be recommended. XXXXX continued her psychotherapy and medications. At XXXXX's request, I talked with her father who accompanied her to the initial visit. I suggested to father that we begin to investigate potential resources for inpatient hospitalization and, because no specialized services are available in this area, I suggested several options including Treatment Center 1, Treatment Center 2, and Treatment Center 3.
At our second visit approximately one week later, XXXXX’s weight had declined to 32.8 kg, a decrease of 1.5 kg. Extremities were pink, but cool. No peripheral edema. Capillary refill was 3 to 4 seconds. Lanugo hair was present. No other new physical findings. I concluded that XXXXX continued to have significant weight loss, bradycardia, amenorrhea, and cachexia related to anorexia nervosa. Her weight was down. We spent most of our second visit discussing hospitalization. I strongly encouraged hospitalization in a specialized eating disorders program and again specifically suggested Treatment Center 1 as one such option.
Ms. YYYYY and her family felt that definitive intensive treatment was required for her eating disorder and associated conditions. They investigated local resources and found only general psychiatric treatment programs. It was the family’s opinion (and ours) that only long term specialized eating disorders treatment would be likely to address her longstanding illness. Such specialty resources, unfortunately, were not available locally. Specialty treatment for eating disorders is far more likely to be effective, and is a more cost-effective option in the long run, especially given Ms. YYYYY’s escalating weight loss. We agreed that if Ms YYYYY did not receive more intensive treatment, she would have continued to deteriorate and would have eventually suffered a catastrophic and potentially life-threatening medical crisis. I certainly supported her psychiatric treatment at a facility where specialized eating disorders treatment was available and I viewed this treatment to be medically necessary, and ultimately, perhaps even lifesaving.
Since beginning treatment at the Treatment Center 1, XXXXX has made measurable progress. In contrast, she had made little progress during her preceding inpatient treatment and in the short time I saw her as an outpatient, she lost weight. At the time she entered the Treatment Center 1 program, there were escalating concerns about her safety, medical stability, and the progression/escalation of her symptoms. Given her dramatic progress, I would certainly support coverage for her previous and continuing treatment at Treatment Center 1, particularly since no similar treatment options are available within our own area (or even within the State of ZZZZZ!). The risk of relapse and/or deterioration is significant if XXXXX’s treatment is discontinued prematurely and her illness was certainly life-threatening if untreated.
Please contact me if you have any questions. I can be reached at 555.555.5555 or by email at RRRRR@UUUUU.edu.
RRRRR SSSSS, M.D., M.P.H.
Professor of Pediatrics and Internal Medicine
Chief, Section of Teenage and Young Adult Health