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Insurance Coverage Letter

For your convenience, we’ve included a sample letter that you can personalize to include your patient’s information and send to his/her insurance company to request coverage of XENICAL.

To personalize your letter, simply fill out the boxes below and then click on "Preview". The letter will appear in your browser.

Required *
   Date * Day Month Year
   Doctor Name *
   Doctor Address * Street
     City

State

Zip 
   Office Phone Number * ( ) -
   Office Fax Number * ( ) -
  Insurance Company Name *
   Insurance Company Fax Number* ( ) -
   Patient Name *
   Patient Date of Birth * Day Month Year
   Patient Insurance # *
  Patient Group # *
  ICD-9 Code Obesity:
278 - Obesity 
278.01 - Morbid Obesity

Diabetes Mellitus:
250 - Type 2 Diabetes         
     250.1 - 250.9
357.2 - Polyneuropathy in Diabetes 
362.0 - Diabetic Retinopathy   
366.41 - Diabetic Cataract
583.81 - Diabetic Nephropathy

Hypertension:
401 - Essential Hypertension     
     401.0, 401.1, 401.9
402 - Hypertensive Heart Disease 
403 - Hypertensive Renal Disease
404 - Hypertensive Heart and Renal Disease 
405 - Secondary Hypertension 

Cardiovascular Disease:
410.9 - Myocardial Infarction 
414.00 - Coronary Atherosclerosis 

Lipid Metabolism:
272.0 - Pure Hypercholesterolemia 
272.1 - Pure Hyperglyceridemia 
272.2 - Mixed Hyperlipidemia 
272.3 - Hyperchylomicronemia 
272.4 - Other and Unspecified Hyperlipidemia 
272.5 - Lipoprotein Deficiencies 
272.6 - Lipodystrophy 
272.7 - Lipidoses 
272.8 - Other Disorders of Lipid Metabolism 
272.9 - Unspecified Disorder of Lipid Metabolism 

Orthopedic:
715.9 - Osteoarthrosis 

Sleep Apnea:
780.51 - Insomnia with Sleep Apnea 
780.53 - Hypersomnia with Sleep Apnea 
780.57 - Other and Unspecified Sleep Apnea 

Other:
575.9 - Gallbladder Disease 

Polycystic Ovarian Syndrome:
256.4 - Polycystic Ovaries 
  Patient Height * feet inches
   Patient Weight * pounds
  Patient BMI *   
Required *