XENICAL Professional - Insurance Coverage Letter


	Virtual Waiting Room

	Reducing Health Risks

	About XENICAL

	Patient Management

	For MCOs

	Safety Profile

	Resources
	> Useful Web Sites
	> Sample Diets
	> Insurance Coverage Letter
	> Insurance Coverage Letter

	Professional Site Home

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 *