Sample letter 2 regarding out-of-network benefits: Download this letter as Word Document
13 July 2007
AAAAA BBBBB
Appeals Coordinator
RE: XXXXX YYYYY
DOB: 06/06/2009
Your Case NumberC-00-88-66-55-44
Dear Ms. BBBBB:
I’ve helped care for XXXXX YYYYY for a medically dangerous eating disorder characterized by pathologic food restriction and weight loss. At the time I first met Ms. YYYYY in May 2007, she had lost more than 20-25 pounds, she weighed 41.8Kg, and she had a calculated body mass index of 16. We made a diagnosis of atypical anorexia nervosa, recommended nutrition counseling and psychotherapy, and strongly encouraged that both be undertaken with experienced clinicians who have experience managing patients with eating disorders. Despite diligent efforts on the part of the family, including several phone calls to your company’s referral line, the family was not able to identify any covered mental health or nutrition services with expertise and experience in the care of patients with eating disorders.
XXXXX began treatment with LLLLL KKKKK R.D. and with therapist MMMMM EEEEE. Though progress was initially modest, Ms. YYYYY has now begun to improve. At my most recent appointment with her (07/11/2007), her weight had increased to 45Kg and her BMI has increased to 17. Frustration has been replaced by a sense of hopeful optimism and Ms. YYYYY is working towards being healthy enough to attend college in the fall.
Ms. YYYYY’s family have paid out-of-pocket for her treatment and have appealed for insurance coverage of XXXXX’s nutrition counseling and psychotherapy. 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 substantial weight loss at the time of her initial presentation (see attached references). We agree that if Ms YYYYY had not receives expert treatment that she would have likely continued to deteriorate and would likely have eventually suffered a catastrophic and potentially life-threatening medical crisis. The risk of relapse and/or deterioration remains significant if XXXXX’s treatment is discontinued prematurely and her illness is certainly life-threatening if untreated.
Please contact me if you have any questions. I can be reached at 734.763.9326 or by email at rosends@med.umich.edu.
Sincerely,
RRRRR SSSSS, M.D., M.P.H.
Professor of Pediatrics and Internal Medicine
Chief, Section of Teenage and Young Adult Health
"There is evidence to suggest that patients with eating disorders have better outcomes when treated [by clinicians] specializing in the treatment of these disorders than when treated in settings where staff lack expertise and experience in treating eating disorders."
(American Psychiatric Association. Treatment Recommendations for Patients with Eating Disorders. Am J Psychiatry. 2006; 163(7 suppl):1-54)
"Assessment and ongoing management should be interdisciplinary and are best accomplished by a team consisting of medical, nursing, nutritional, and mental health disciplines. Treatment should be provided by health care professionals who have expertise in managing adolescent patients with eating disorders and are knowledgeable about normal adolescent physical and psychological development."
(Society for Adolescent Medicine. Eating Disorders in Adolescents: Position Paper of the Society for Adolescent Medicine. J Adolescent Health. 1995; 16:476-480)