Dr. A.

Smith
4990 East Mediterranean Drive,
Suite A, Sierra Vista, AZ 85635
Phone: 520-439-5186
Fax: 520-439-4466

August 18, 2021

P.O. Box 2210

Massachusetts

Re: SpongeBob SquarePants DOB: June 19, 1996

To Dr. Stephen Burpee, MD,

I am writing on behalf of my patient, SpongeBob SquarePants to document the medical

necessity of being evaluated for weight reduction surgery for the treatment of his morbid
obesity relating type 2 diabetes. Tis letter provides information about the patient’s medical
history and diagnosis and a statement summarizing my treatment rationale.

Patient’s History and Diagnosis:

SpongeBob SquarePants has been diagnosed of morbid obesity in relation to his type 2 diabetes
and he is very eager but has been having difficulty in losing weight after 2 years despite all the
recommendations I gave such as changing his diet, adding exercise to his daily routine and
prescribing phentermine. Our last resort for him to lose weight as I can see is for him to
undergo weight reduction surgery to prevent future complications of his type 2 diabetes
mellitus.

Duration:
2 weeks

Summary:
In summary, weight reduction surgery is medically necessary for this patient’s medical
condition. Please contact me if any additional information is required to ensure the prompt
approval of weight loss surgery.

Sincerely,
Dr. A. Smith