Help me decipher my medical policy

peachpie
on 10/8/17 6:59 am - Philadelphia, PA
RNY on 04/28/15

So I'm 2.5 years out, l and have lost 75% of my excess weight. Weight has been stable for over a year now. I have excess skin on my abdomen and arms. Unless insurance covers it- PS won't happen. I looked online at my hmo's medical policy (posted below), pertinent info bolded. The language around removals after bariatric surgery wasn't there before.

In terms of how I look, my lower abdomen, pannus, hangs to the pubis, definitely not below. No rash or infection has occurred in that lower area. Where I am getting irritations is at the navel line- where my muffin top deflated. I also started getting irritations where a skin fold used to be on my back- toward the bra line. I'm wondering if I could make the case for medically necessary removal, albeit my irritations are at a higher level than what I'm interpreting the policy below to cover.

Thoughts?

MEDICALLY NECESSARY

PANNICULECTOMY/EXCISIONS OF REDUNDANT SKIN OTHER THAN ABDOMEN/PANNUS
When performed as a cosmetic service, panniculectomy is a benefit contract exclusion for all products of the Company and is not eligible for reimbursement consideration. However, panniculectomy is considered medically necessary and, therefore, covered when all of the following criteria are met:
The panniculus (pannus) hangs to or below the level of the pubis
Persistent, chronic irritation and/or infection are present in the area of the hanging panniculus, along with any of the following:
Ulceration
Necrosis
Suprapubic intertrigo
Panniculitis
A three-month course of medical therapy has been ineffective in managing (or controlling) symptoms.

Examples of agents that may be used for conservative treatment are: topically applied skin barriers, supportive garments, and antifungal, antibacterial, and moisture-absorbing agents.
The panniculus (pannus) causes significant interference with activities of daily living (e.g., caring for areas of redundant skin and associated hygiene) or problems with ambulation.
If panniculectomy is performed to correct redundant tissue after massive weight loss, all of the following criteria must also be met:
Stable weight is maintained for at least six months.
If the individual has had bariatric surgery, panniculectomy should not be performed until at least 24 months after the bariatric surgery.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.

All requests for the procedures mentioned in this policy require a review by the Company and must include all of the following:
Dated photographs of the panniculus hanging over the pubis and of the panniculus or redundant skin elevated to expose the chronic, persistent, and refractory skin infection or irritation. chronic, persistent, and refractory skin infection or irritation.
Office notes from the treating professional provider that reflect the chronic, persistent, and refractory skin infection and/or irritation, despite optimal medical care over a three-month period.
A listing of the medications that were used to treat the chronic skin infection or irritation during the three-month period and the length of time that the medications were used.
Documentation when applicable, that demonstrates massive weight loss, weight stability, and date of bariatric surgery.

5'6.5" High weight:337 Goal Weight:195 Current Weight: 197

Laura in Texas
on 10/8/17 7:59 pm

I would see your PCP and have your skin irritation documented and ask for a prescription to treat the irritation while you investigate further.

Good luck!

Laura in Texas

51 years old; 5'7" tall; HW: 339 (BMI=53); CW: 140 (BMI=22)

RNY: 09-17-08 Dr. Garth Davis

brachioplasty: 12-18-09 Dr. Wainwright; lbl/bl: 06-28-11 Dr. LoMonaco

"If what you're doing doesn't work, change what you're doing - don't complain that it doesn't work."

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