Sep 28, 2017
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I have an adolescent female patient who wants to get a breast reduction due to the effects her breast size have had on her, contributing to her depression and causing chronic pain. She has been wanting to have this procedure for more than a year but just recently brought it up to me. She has already met with a surgeon who recommended the procedure, and suggested she meet with me to talk about this. After discussing the impact this has had on her life, I agree that she would likely benefit from having a reduction. A few days after this discussion, mom called the office asking for a letter of medical necessity because the insurance denied the claim for surgery.

Do any of you have experience with writing this sort of letter? I was thinking that I might be asked to write a letter in support of the procedure, but I was not expecting to write a letter of medical necessity; I don't know if I am the right person to write this letter, since I am not the one recommending or performing the procedure. I am wondering if it would be fine to write a letter summarizing the problems associated with her breast size as stated by the patient, and indicate that I am in support of the procedure, but not include any wording to the effect that I consider this medically necessary.

I've never written a letter for anyone seeking psychiatric clearance for surgery before, so I'm not sure what needs to go into this. I'd appreciate any thoughts from those who may have some experience in this area. Thank you!
 

wolfvgang22

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You can write a letter supporting the procedure as you suggest if you want, but recommend to the patient that the surgeon write the letter of medical necessity. I have a relative who had the same situation and procedure. It is quite common for surgeons to write these letters for breast reductions.
 

calvnandhobbs68

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Agree with the above. I haven't had to write one of these but from what I know, the person performing the procedure typically writes these letters, as they are the ones who can speak the most to the risks and benefits of the procedure and that, in their opinion, the benefits of this procedure would outweigh the risks for the patient. The surgeon also has much more experience in the follow up of patients with this procedure and would be able to speak to the fact that they would expect significant benefit from this procedure for this patient based on their pre-op eval and typical followup results.

You could certainly write a letter supporting the procedure that patient can bring to the surgeon as well that they could attach to the letter of medical necessity though, saying that if the procedure were to go as planned you would expect significant improvement in patient's depressive symptoms secondary to chronic pain etc etc.

I don't think this is "psychiatric clearance" for surgery in the sense of clearance like for transplant evals or gender reassignment surgery (where a lot of the time the surgeons won't even perform the procedure without "clearance"), it's more of an insurance company won't pay for this so can you write me a letter so they'll pay for it.
 

NickNaylor

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I think it is appropriate to comment on your impressions and how the patient's condition is affecting her from a psychiatric perspective. I agree with @wolfvgang22 that it is not your place to write the letter of medical necessity - that is more the surgeon's job. They might refer to your letter in their own letter if they would like. Ultimately, you are not a surgeon and are not qualified to discuss whether this procedure is medically necessary or not. However, you are qualified to talk about how this condition might be affecting her mental health.
 

splik

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They don't need a letter and I don't do them. I have a lot of experience doing pre-operative psychological evaluations. your documentation of the patients mental state and anticipated outcome and risks/benefits of the procedure will be sufficient. As a psychiatrist you should never opine on the "medical necessity" of surgery (except maybe DBS for OCD), and instead just opine on whether it the procedure would be reasonable management from a psychiatric perspective, and the potential psychological outcomes and whether the patient has capacity to proceed.

In this case you might describe how the pain and body image issues related to large breasts is a factor in the patient's depression and how treatment of depression by pharmacotherapy and psychotherapy alone have not been sufficient. You would also want to address whether the patient's expectations are realistic, and the absence of psychosis or BDD influencing the patient's decision to seek breast reduction etc.
 

LadyHalcyon

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They don't need a letter and I don't do them. I have a lot of experience doing pre-operative psychological evaluations. your documentation of the patients mental state and anticipated outcome and risks/benefits of the procedure will be sufficient. As a psychiatrist you should never opine on the "medical necessity" of surgery (except maybe DBS for OCD), and instead just opine on whether it the procedure would be reasonable management from a psychiatric perspective, and the potential psychological outcomes and whether the patient has capacity to proceed.

In this case you might describe how the pain and body image issues related to large breasts is a factor in the patient's depression and how treatment of depression by pharmacotherapy and psychotherapy alone have not been sufficient. You would also want to address whether the patient's expectations are realistic, and the absence of psychosis or BDD influencing the patient's decision to seek breast reduction etc.
Have you ever done evaluations for a pain pump and/or stim device?