What to Include in Your Cover Letter for Your Preauth Submission
It's easier than you think
Hi Everyone,
Okay, so you’ve gone through at least three months of conservative care, have two Medical Necessity letters, included your FCE, and all the other needed diagnostics, and you’re ready to write your cover letter… and you freeze.
Where do you start? What is it you want to say to convince your insurance that you need this surgery? You start to feel this is high stakes that can make or break their decision.
Take a deep breath because this one is easy.
In a normal preauthorization request for any other general surgery, you don’t need to do any of this. You don’t need a cover letter. You don’t even need to submit your own preauthorization.
Typically, the physician’s office requests the preauth, and I guarantee they aren’t writing a cover letter to the insurance about your life history with this disease.
However, Lipedema Reduction Surgery (liposuction) is primarily performed by Plastic Surgeons, and since their work is mainly cosmetic, those docs don’t have experienced staff to bill insurance. So it’s up to us, the patients.
Lipedema patients have traditionally had to submit their own preauth up to this point (hopefully this will change one day soon). For whatever reason, a cover letter was added as part of the checklist. And someone, somewhere, made it the rule that you must write your cover letter describing “your journey” of your disease and why you need surgery.
I personally came into this personal preauth game only a year ago, and I also had to write a cover letter. The entire time I’m shaking my head because this isn’t standard for a preauth. And I’m not sure how much insurance really takes your anecdotal story into consideration to sway the preauth in your favor. They look at facts, research, Medicare guidelines, Standard of Care…etc., etc.
I believe that in the future requesting preauth becomes the physicians’ responsibility and not ours, and there will no longer be a need for a cover letter.
But for now, here we are; here to write “our story.”
Despite this, writing a cover letter isn’t all bad. It is the one time you can sit down and go through your history and all you’ve done for yourself despite the barriers you’ve come up against along the way. It’s the one time you can see how strong you really are.
So what should you add to your cover letter?
You don’t have to be a fantastic writer to write this letter. And the letter can be as long or short as you like (mine was three pages long). Even if you put in the basics from the list below, that is good enough. Believe me; it will not make or break your preauth.
Here’s a list, with examples, for your cover letter to include:
1. An Introduction
Every letter needs an intro, whether you’re applying for a job or writing a formal letter to a client. A short intro to why you’re writing them a letter in the first place is a good start.
Here’s an example:
I am requesting a pre-authorization for Liposuction surgery with Dr. _________ for my Lipedema treatment.
Lipedema is a loose connective tissue disorder triggered hormonally (usually through puberty, pregnancy, or menopause) and affects adipose tissue. Lipedema is not affected by diet and exercise, unlike metabolic fat. It is a common yet largely unrecognized disease that primarily affects women.
I am requesting preauthorization and an out-of-network exception for my needed surgeries and surgical specialists.
This is short and sweet, and you can say this in your own words however you like, whichever makes you comfortable. I only insist that you are clear and direct in your communication.
2.Tell your Lipedema Story
Start from puberty, and write about any physical and mental challenges you’ve endured. Talk about how you were either misdiagnosed or not diagnosed at all and how that has negatively impacted your life. Include everything.
This is actually quite cathartic. As you write down everything you’ve gone through, you’ll see that you’ve had to advocate for yourself a lot. You’ll see how strong you’ve been even in your worst times. And if you have any doubt about whether or not you need surgery, I hope that this part of your writing will convince you that YES! You need surgery! And you certainly, without-a-doubt, deserve it.
3.Describe How You Were Diagnosed
Give a short synopsis of how you came to a formal diagnosis. This solidifies that you do have a legitimate medical condition verified by a physician. Every one of our stories is an individual one. Let them know yours.
Here is part of my writing in my cover letter about how I was diagnosed:
I spent a couple of years and much diagnostic testing and treatment for my symptoms of pain and fatigue. I’ve had an echocardiogram, which was normal. I’ve had vein ablation for varicose veins, thinking that was the problem with my heavy legs. I’ve also had an MRA for pelvic varicosities, which were negative. I’ve been tested for rheumatoid arthritis, also negative.
I have severe migraines, which are managed with medication. Otherwise, I am completely healthy. Regardless of all the medical tests and physician appointments over years, no doctor had mentioned nor assessed me for Lipedema.
My Lipedema diagnosis was a fluke. I was reading a story about another woman who struggled with this disease. As I read, I started recognizing myself in her story. As a nurse for over thirty years and certified in case management for 20+ years, I was shocked I’d never heard of Lipedema…
…Unfortunately, there are no specialists in Oregon for diagnosis, so I researched which educated physicians could make a proper diagnosis. I found Dr. Karen Herbst, an endocrinologist and Lipedema expert in Los Angeles.
I decided to make an appointment with Dr. Herbst, and in September 2021, I took a chance and flew down to California for a consultation.
Dr. Herbst did a thorough exam and gave me a formal diagnosis. I have that clinical visit attached with my preauthorization request.
4.Write a Short Outline of Your Conservative Care
Include each non-surgical intervention you’ve completed and also how your body has responded to that treatment. Whether it was beneficial or not. Let your insurance know despite conservative treatment, Lipedema is a progressive disease that eventually needs more aggressive treatment than compression hose and physical therapy visits.
Here’s an example of what I wrote on this part of the cover letter:
Since I received my diagnosis, I’ve been working with a Lymphedema Specialist. She has shown me how to perform manual lymph drainage. She also got me a lymph machine. I use this machine daily, and I believe this has helped with symptom management of my Lipedema. I wear compression hose, which I had been doing before diagnosis.
However, as my disease progresses, my mobility has declined. I’m unable to walk more than 200 feet without getting short of breath, having an elevated heart rate, and breaking out in a sweat from the exertion.
My adipose tissue has developed into hard fibrosis, which causes me constant pain. I’m unable to walk up a flight of stairs. The pain in my knees has worsened and sometimes “gives,” which has caused me to fall frequently. I cannot get surgical treatment for my knees because I’m now in a high-risk category due to my weight and the negative impact it will have on any surgery.
My quality of life has decreased significantly. I can perform about 15-30 minutes of housework, then become fatigued. I’m unable to walk for extended periods without significant pain and fatigue.
5.A Conclusion to Your Letter
Ending your cover letter should emphasize what you’re requesting from them. Keep it simple and straightforward.
Here’s an example:
My request to you, my Insurer:
I am requesting preauthorization and an out-of-network exception for my needed surgeries and surgical specialists.
Add whatever you like that backs up your request, such as addressing the Standard of Care, how this surgery is now being covered by other major medical insurance companies and also through Medicare (this is useful for those smaller regional insurance plans, like mine, which doesn’t have any written plan language addressing Lipedema).
6.End Your Letter With a Formal Sign-Off
Along with your sincerely ending, make a list of the enclosed items you’re submitting. This is beneficial for them but also for you. This will keep you organized and make sure all of your documentation is in place.
Here’s an example (although not a full list of what you’d submit):
Enclosed:
*Prior authorization request form (1 page)
*Letters of Medical Necessity for Lipedema (4 pages)
*Physical therapy progress notes including measurements and photos (28 pages)
*Physical Capacity Evaluation (5 pages)
and YOU…ARE…DONE!
Writing this letter will take some time, but hopefully, the guidelines I’ve given you here will help make it easier for you.
If you have any questions, let me know!
Good luck! You can do it. :)
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