AspireAssist Non-Surgical Weight Loss Procedure

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INSTRUCTIONS FOR WRITING AND SUBMITTING YOUR COVER LETTEROn the following pages, we have provided a sample cover letter for your convenience. If you choose to use this template, please be sure to fully review and customize the letter so it is true and accurate for you. Click on the blue text on the following pages and fill in with the appropriate information:Member ID Number: Please refer to your insurance card.Insurance Address: If this information is not on your card, you can call the number on your card to request the mailing address or locate it on their website.Physician’s NPI Number: Call your physician’s office for this number, or look it up by first and last name online: of Medical Services Included (“I also request reimbursement for other aspects of this therapy, including…”): This template provides a list of typical items included in the cost of therapy. Please customize this list as necessary to reflect the aspects of the therapy that your physician has included in the cost that you have paid. You may need to add or delete some items. These items may or may not be broken out in your receipts. List of Items Billed: This template lists some common items that are included in the billing. Please review your receipts and edit the list as necessary to match the items that are listed in your receipts or documentation from your physician. You may need to add, edit, or delete items. If there is only one lump sum amount listed, this list is not necessary. Starting BMI: To find your starting BMI, enter your height and starting weight here: all blue text has been edited and no longer appears as blue, please read the letter fully to ensure that it is true and accurate for you. Please remember that this is just a template; you are encouraged to customize it as you see fit, including the black standard text.***Important! Make sure all text is BLACK before printing. You may need to change the color of the blue text to black if it does not change automatically***Print and sign the letter. Follow the instructions in the Empowerment Packet to mail / fax the letter on the following pages, along with the recommended attachments, to your insurance company once it is customized (remove this instructions page before sending). Questions, or difficulties editing or printing this document? Please contact an AspireAssist insurance specialist at 877-203-1058.PLEASE DO NOT SEND THIS INSTRUCTIONS PAGE TO YOUR INSURANCE COMPANY! <your full name><your street address><city, state and zip code><phone number><email address>Member ID Number: <ID number>Date of Birth: <date of birth><today’s date><insurance company’s name><insurance company’s address><insurance company’s city, state, and zip>Re: Itemized Claims Request and Procedure Description for <your full name> To whom it may concern:The purpose of this letter is to request claims payment for the AspireAssist? weight loss procedure for the treatment of my obesity diagnosis (ICD-10 Code E66.01). My physician, <your physician’s name>, NPI number <physician’s National Practitioner’s Identifier (NPI) number>, determined that the treatment of my morbid (severe) obesity is medically necessary, and in my physician’s opinion, AspireAssist therapy was the most appropriate treatment for me. The AspireAssist System is an FDA-approved device (P 150024) in commercial use in US and Europe, for weight loss in patients with Class II or Class III obesity. The therapy has been the subject of six clinical trials in the US, Mexico, and Europe, involving, in aggregate, over 400 patients for up to five years. When used in conjunction with Lifestyle Therapy, the AspireAssist produces a clinical benefit comparable to bariatric surgery, without the complications or ongoing side effects typical of bariatric surgery and at a fraction of the cost.My physician did not submit claims for my procedure or related care. Accordingly, per my coverage policy, I request that coverage and payment be provided for AspireAssist Therapy which includes the gastrostomy tube placement (CPT 43246) performed on <your procedure date> at <name of the facility your procedure was done>. I also request reimbursement for other aspects of this therapy, including lifestyle therapy for the first year, evaluation and medical management visits to my physician for the first year of therapy, the AspireAssist gastrostomy tube (“A-Tube”), and the AspireAssist First Year Kit <review previous list and add any additional items here>. I paid a total of $<amount> for this procedure, which includes the following items (with attached receipts / invoices): $<amount>: Professional Fees for <your physician’s name> for placement of the AspireAssist A-Tube (CPT 42346), the initial consultation, and all medical follow-up visits. $<amount>: Facility Fee for CPT 43246 EGD with placement of a percutaneous gastronomy tube at <facility name where your procedure was done>.$<amount>: Anesthesiologist Fees for <anesthesiologist’s name>.$<amount>: The AspireAssist A-Tube Kit.$<amount>: The AspireAssist First-Year Kit.I am <#> feet <#> inches tall. At the time of my initial consultation I weighed <starting weight> pounds and my BMI was <starting BMI> kg/m2. I also had the following obesity-related medical condition(s): <list obesity-related conditions such as stress incontinence, sleep apnea, high blood pressure, high cholesterol, diabetes, gastroesophageal reflux disease, arthritis, depression, venous stasis disease, coronary artery disease, chronic obstructive pulmonary disease, shortness of breath, limited mobility, skin conditions (if none, delete this sentence)>. Prior to having this procedure, I attempted the following weight loss methods: <list previous weight loss methods>. Since I started AspireAssist therapy, I have lost <#> pounds and <if applicable, describe any other benefits you’ve experienced, such as medication decreases>.To assist you in reaching the appropriate coverage decision, I am including with this letter the following documents: (i) my Member Claim Form; (ii) My receipts/invoices; (iii) Itemized Billing and Procedure Description for the AspireAssist; and (iv) FDA Approval Letter for the AspireAssist. Thank you for considering my request. I can be reached at <phone number> or by email at <email address>.Sincerely,<your name> ................
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