Sharing: My Cover Letter to Aetna Asking for Out of Network Coverage – It’s All True!

In an earlier post, I walked you through the process I used to get insurance precertification and out of network approval in one week flat. This is the cover letter I wrote that went with my request for out of network coverage and a single case agreement. I think it’s a great letter, and I borrowed a lot of information from Dr. Schwartz’s blog to make it. Note I redacted two paragraphs that came from the an insurance advocate’s process that they own, as it is part of a template for a different cover letter that they recommend be included in the original precertification package (different letter). Additionally, not everyone agrees with all the info I used to create this letter, but this is what I sent, and it worked for me, in my situation. Enjoy!

Aetna
Aetna Address Redacted
Aetna Fax Redacted

RE: Name, DOB – non participating provider request

Member ID: Redacted

January 13, 2021

To Whom It May Concern:

On January 8, 2021 I submitted my precertification package requesting approval for surgeries to treat my diagnosed disease of lipedema. I have not yet heard the outcome of the precertification request.

Additionally, I requested a single case agreement with my surgeon Jaime Schwartz, MD, who is out-of-network as an in-network provider, and that he be paid as an in-network provider, by submitting the Nonparticipating Provider Request form with my precertification package.

In submitting this request for non participating provider specialist on my “Precertification/Preauthorization Nonparticipating Provider Request,” Form GR-67353-12. I find there is not enough room on the form to justify the use of this specific specialist in lieu of a general surgeon, or general cosmetic surgeon or other possibly in-network surgeons. I am requesting that this information be added to my package as justification for using Dr. Schwartz, a lipedema specialist:

Jaime Schwartz is welcoming to accept high risk cases like mine, where my Body Mass Index is high and I have a history of a blood clot. The other surgeon I consulted with (Dr. Redacted) required me to lose weight, which is not possible having lipedema and not metabolic fat.
Schwartz has specialized equipment and has several different types of equipment at his disposal.
Two paragraphs from an insurance advocate’s cover letter template have been redacted.
Jaime Schwartz is a board-certified plastic surgeon and renowned lipedema specialist. Founder of Total Lipedema Care in Beverly Hills, CA, Dr. Schwartz has dedicated part of his private practice to helping women hindered by this disease. Dr. Schwartz continues to research and figure out answers to this complex disease that seems to be driven by a woman’s hormones. Lipedema specialists, like Dr. Schwartz, are finding ways to reach these women in the early stages so they can have the emotional and physical support as well as treatment options to live with this disease.
Lipedema specialist Dr. Jaime Schwartz is dedicated to taking a further look into this condition and how he can help women suffering from this potentially-debilitating disease. Schwartz can help patients with an early diagnosis which is essential to getting the early intervention help and emotional support that lipedema patients need. Places like Total Lipedema Care are centered around giving women surgical options, treatment plans, and additional avenues for support in order to have a better quality of life while living with this disease.
Most women who have lipedema are embarrassed about how they look. Lipedema causes a woman’s lower half, particularly the legs, calves, and hips to be over-sized while the upper torso remains the same. One of the main reasons Lipedema often goes undiagnosed is because it is commonly mistaken as a weight issue by other medical professionals. It is a physically and mentally challenging disorder and most women go through it alone. Finding a lipedema specialist, like Dr. Schwartz, is imperative to the support that every woman needs on how to deal with this disease and keep it from progressing. Lipedema patients need to feel comfortable with their specialist in order to convey what they are dealing with and discuss any issues. A definitive diagnosis allows a lipedema specialist like Dr. Schwartz to have a better knowledge and understanding of what each patient is experiencing in order to devise a treatment plan.
With his extensive knowledge of this disease, Dr. Schwartz can help rule out any other conditions and give an accurate diagnosis. This can allow for the right treatment options to begin promptly. Dr. Schwartz is extremely skilled in all aspects of lipedema, from its earliest stages to the more severe, advanced stages. This knowledge allows him to monitor and help his patients every step of the way. Dr. Schwartz and the professional staff at Total Lipedema Care can give nutritional guidance, recommend physical therapy or water exercise programs, surgical and nonsurgical treatments, and even psychological counseling.
Schwartz is not only a lipedema specialist but also a board-certified plastic surgeon. Because of this, he can provide treatments that offer relief from certain lipedema symptoms. Once such treatment is water-assisted liposuction (WAL). This procedure essentially decreases the congestion and inflammation in the legs where lipedema is most prevalent. Similar to, but not, a cosmetic liposuction, fat in the targeted treatment areas will be removed. Dr. Schwartz also employs the SAFE liposuction technique – separation, aspiration, and fat equalization – to get as much fat out as possible while not putting the shape of the area in jeopardy.
Another surgical treatment option for lipedema may include excess skin removal for areas that have lost elasticity. This skin can actually hinder lipedema patients, especially if it gets infected, impairs the mobility of the patient, or prevents compression garments from fitting properly.
Since there is no cure for this hereditary disease, working closely with a lipedema specialist like Dr. Jaime Schwartz will help improve symptoms, provide ongoing care, reduce leg size or complications with surgical help, and provide emotional support. Living with this disease is a daily challenge but having a relationship with a lipedema specialist like Dr. Schwartz is beneficial in so many ways.