RECONSTRUCTIVE SURGERY INSURANCE LETTER

Good luck. Here you go..... Member Name: Member Id: Member Date of birth: Group number: Member address: Member phone and fax number: Member email address: Re: Requesting Expedited Approval for Excision of Excess Skin after Massive Weightloss - Medical Necessity Predetermination Dear Patient Care Management Department- Cosmetic Review Team: I am writing this letter to request expedited approval for medically necessary surgical procedures listed below: Abdominoplasty (extended to the lumbar) Cpt Code: 15831 Buttock Lift 15835 Brachioplasty Cpt Code: 15836 Mastopexy Cpt Code: 19316 Thighplasty Cpt Code: 15832 Hip-plasty Cpt Code: 15834 I am not requesting these surgeries for cosmetic reasons. These surgeries are reconstructive following massive weight loss per the American Society of Plastic Surgeons and The American Medical Association. Per customer service representatives with IBC there are no exclusions or preexisting clauses on my policy as long as procedures are medically necessary or will correct functional impairment. Loss of excessive weight may lead to redundant skin. Excision of redundant skin after weight loss in areas such as, but not limited to, the abdomen, lumbar region, arms, and/or thighs is medically necessary for intertrigo, monilial infestations, and/or panniculitis that have failed to resolve with conservative measures. Abdominoplasty is a surgical procedure used to alter the abdomen by removing excess skin and/or fatty tissue and tightening a lax anterior abdominal wall. Potential complications from abdominoplasty include blood or serum collections beneath the flap, infection, tissue loss, and protrusion of the abdominal wall between the left and right rectus abdominis muscles. Abdominoplasty and excision of redundant skin after weight loss is medically necessary and is performed for the treatment of the following conditions: suprapubic intertrigo, monilial infestations, and/or panniculitis when conservative treatment measures have failed. Excision of redundant skin after weight loss performed for all other indications is considered cosmetic. If cosmetic surgery is included in a group benefit contract as a covered service, the service is provided to members in such groups in accordance with the terms of the contract. I had gastric bypass surgery June 6, 2002 and have successfully lost 137 pounds. I weighed 305 pounds (BMI 47.4) the day of surgery and now weigh 168 pounds (BMI 26.3). Although I have lost the weight and feel better about myself and am healthier I am now left with 25 pounds of excess skin all over my body. The excess skin has affected the physiological function of my abdomen, lumbar, buttocks, arms, thighs, and breasts. The excess skin has also caused me functional impairments and quantifiable medical problems, such as uncontrollable and untreatable fungal dermatitis, folliculitis, intertrigo and suprapubic intertrigo, yeast, fungal, and bacterial infections. I have problems with hygiene as it is very difficult to keep clean between the skin folds and I often take three to four showers a day and still never really feel clean nor am I odor free. Even though the surgeries I am requesting are considered reconstructive surgeries by The American Society of Plastic Surgeons and The American Medical Association some health insurance companies label them as cosmetic surgeries. I just wanted to point out to you that my policy states that cosmetic surgery is covered if it is medically necessary and if it is being performed to correct a functional impairment caused by a covered disease, injury, or congenital birth defect. All of my doctors treating me have stated and documented the medical necessity for me to have these procedures performed. The following are functional impairments as a result of the excess skin: intertrigo, suprapubic intertrigo, fungal dermatitis, folliculitis, rashes, yeast and bacterial, infections, hygiene issues- I can never keep skin folds clean, back pain, neck pain, shoulder pain, problems lifting things over 10 pounds, problems sitting for long periods of time, problems standing for long periods of time. The covered disease was Morbid Obesity. The treatment for Morbid Obesity was gastric bypass. The excess skin is a result of treatment (gastric bypass) of a covered disease (Morbid Obesity) - which qualifies me for reconstructive surgery. In addition, as stated below, reconstructive surgery is done to improve function, as well as approximate a normal appearance. The pain is becoming stronger with each day in regards my abdomen, lumbar, buttocks, arms, thighs, and breasts. The excessive skin is so great that I am experiencing degenerative disease in my lower back. My excessive skin folds on my abdomen, lumbar, buttocks, arms, thighs, and breasts are a direct result of the extreme weight loss of 137 pounds. It is my understanding that the removal of the skin can take away the folds that trap moisture to prevent the infections. A requirement of the gastric bypass surgery is that I must keep up my exercise to be successful. Exercise causes me great pain because of the excess skin constantly rubbing together. The more I exercise the more I sweat and as a result of the sweat (trapped moisture) the rashes and infections are increasing and becoming worse. This has resulted in me becoming less active. In addition, please note that these functional impairments of the skin cannot be managed with non-surgical methods. First, you cannot do anything about the excessive skin without surgery. Second, the rashes and infections caused by the skin rubbing together between my abdomen and pubic area, thighs, breast, and arms cannot be cured without taking what is causing the rubbing away (the skin). The creams and lotions have done nothing the last seven or eight months to treat my condition. Additionally, without removing the skin, we cannot correct the abnormalities/deformities that have been created as a result of the treatment of the morbid obesity. I have been treated by Dr. Mary Fleshchli since January 2003 and have been prescribed Loprox and Niacin cream, and Zeosorb powder for my rashes, intertrigo and suprapubic intertrigo, fungal dermatitis, folliculitis, and yeast,fungal, and bacterial infections. However, since the excess skin constantly rubbing together causes them to get infected on a daily basis they never go away or heal. I am basically raw from every movement that I make as I have excess skin all over my body. The medications do not help as the excess skin still remains. Pictures have been included for your review however because I am dark skinned it is quite difficult to see rashes, intertrigo and suprapubic intertrigo, fungal dermatitis, folliculitis, and yeast and bacterial infections in pictures however they can clearly be seen in person. Walking, standing, or sitting for long periods of time, lifting things over ten pounds, bending, reaching, carrying and stooping are all very difficult as the pressure that the excess skin places on my already curved spine and extremities is quite painful and makes being active very difficult. I am in constant pain and currently am on Bextra, Soma, and Elavil medications for pain relief. I often have to seek assistance from family and friends with household chores that involve lifting, carrying, reaching, moving things or assistance with things that require me to stand up for long periods of time. I also have problems with exercising as the skin is constantly in the way and cause me problems with range of motion. As a result of the excess skin on my breast I have great difficulty with giving my self-breast exams. This worries me greatly as Breast Cancer runs in my family and because of all of the excess skin on my breast I can not feel the difference between excess skin or breast tissue or a legitimate lump. I recently had a breast exam from my OB-GYN -Dr. Traci Nivens, and she even had difficulty giving me a breast exam because of the excess skin on my breast. I also have rashes and infections under my breast caused by the constant rubbing of excess skin against my abdomen. She has also noted in her letter the difficulties I have with performing sexual intercourse due to extreme pain caused by the excess skin in my thigh and pubic area. My pannus (excess skin from abdomen) hangs below my pubic area and constantly rubs it all day long causing open sores that bleed. My arms have three to four inches of excess skin hanging that constantly rubs my sides and causes open sores that bleed. My breast hang down to and constantly rubs my abdomen causing open sores that bleed. My thighs have 5 to 6 inches of skin that hangs down and rubs constantly with every movement I make causing open sores that bleed. I also have severe back pain, neck pain, shoulder pain, and tingling in my fingers and arms. The excess skin hanging off of my body is adding unwanted pressure to my spine and causing me various problems with movement. I have been seeking Chiropractic adjustments and physical therapy for more than seven months, however because of the excess skin hanging off of my body my Chiropractor - Dr. Sandra Sullivan states that the pain will persist until the excess skin is removed. She believes that my back, neck, and shoulder pain will be improved once the skin is gone. I am seeking approval for the following surgeries based on medical necessity: Abdominoplasty (extended to the lumbar) Cpt Code: 15831 Buttock Lift 15835 Brachioplasty Cpt Code: 15836 Mastopexy Cpt Code: 19316 Thighplasty Cpt Code: 15832 Hip-plasty Cpt Code: 15834 The codes that are related to my signs and symptoms are below Candidiasis (ICD-9: 112.89, 112.9) Permanent overstretching of the anterior abdominal wall (ICD-9: 928.84) Large or long abdominal panniculus (ICD-9: 278.1) following weight loss in the treatment of morbid obesity and resulting in the Difficult ambulation (ICD-9 724.8). Structural defects of the abdominal wall (ICD-9 701.8/708.9) Uncontrollable intertrigo (ICD-9: 695.89) Crease dermatitis, (ICD-9: 692.9) Large overhanging pannus (ICD-9: 701.8) Macromastia (ICD-9: 611.1) Ptosis of the breast (ICD-9: 611.8) Chronic breast pain (ICD-9: 611.71) Lower back pain and Postural backache (ICD-9: 724.2) Upper back (ICD-9: 724.1) Neck (ICD-9: 723.1) Shoulder pain (ICD-9: 719.41) Skin rashes (ICD-9:682.2, 682.3) Pressure sores (ICD-9:707.0) Dyspareunia (ICD-9:625.0) Pelvic pain (ICD-9: 625.9) The actual physiologic functions affected by excess skin Intertrigo and Suprapubic Intertrigo Fungal dermatitis Folliculitis Rashes Yeast/bacterial/fungal infections Hygiene issues- can never keep skin folds clean Back pain Neck pain Shoulder pain Problems lifting things over 10 pounds Problems sitting for long periods of time Problems standing for long periods of time Problems walking for long periods of time Problems exercising Problems taking care of difficult household chores without assistance Problems bending and stooping Problems reaching Problems carrying Sexual Dysfunction and pain because of excess skin Tingling in arms and fingers Dr Patrick H. Pownell is the plastic surgeon who will be performing the procedures as soon as approval is given. He is an In-Network surgeon and we are patiently waiting for your approval so that we can proceed with surgeries before fall semester in college starts for me August 25th. His contact information is listed below. I am requesting the insurance company to make a "good faith" review of this request. I ask that you review all medical documentation included and that you look at all of my medical issues, and view photographs before a determination is made. The photos do no justice in showing the abnormalities in my skin, as I am dark skinned. I am available to fly to your location and appear in person if you need to see me to have a better idea of how the excess skin is affecting my health. I ask that you approve these surgeries based on the terms and conditions on my policy, my doctor's recommendation and medical necessity. These surgeries are beneficial to restore physiologic function and correct functional impairments within my epidermis, dermis, joints, and muscles. There are no exclusions in my policy that would eliminate me from having the skin surgically removed from my abdomen, lumbar, buttocks, arms, thighs, and breasts to allow me to live free of pain and functional impairments. The sooner we hear from you, the sooner my surgeries can be scheduled. I thank you in advance for your assistance in a timely manner. Sincerely, Teena A Treatment of Redundant Skin after Massive Weight Loss Recommended Criteria for Third-Party Payer Coverage Background: The American Society of Plastic Surgeons (ASPS) is the largest organization of plastic surgeons in the world. Requirements for membership include certification by the American Board of Plastic Surgery. ASPS represents 97% of the board-certified plastic surgeons practicing in the United States and Canada. It serves as the primary educational resource for Plastic Surgeons and as their voice on socioeconomic issues. ASPS is recognized by the American Medical Association (AMA), the American College of Surgeons (ACS), and other organizations of specialty societies. Definitions: Morbid obesity is defined by a patient weighing at least 100 pounds over the ideal body weight or more than twice the normal weight for height. It is estimated that as many as nine million people in the United States suffer from morbid obesity. The death rate may range up to twelve times that of non-obese persons of the same age and sex. Associated medical conditions include coronary heart disease, hypertension, diabetes mellitus, osteoarthritis, respiratory distress, gall bladder disease and psychosocial incapacity. Improvements in the surgical correction of morbid obesity via gastric partitioning procedures as well as more effective non-surgical diet regimens have allowed increasing numbers of morbidly obese patients to undergo successful and sustained massive weight loss. While the medical/health benefits of massive weight loss are obvious, different problems may arise as a result. Massive weight loss can lead to extensive redundancy of skin and fat folds in varied anatomic locations causing functional problems. These areas include medial upper arms, breasts (male and female), the abdomen and medial thighs. Redundant skin folds predispose to areas of intertrigo, which can give rise to infections of the skin (fungal dermatitis, folliculitis, subcutaneous abscesses). Commonly affected areas are the overhanging pannus of the lower abdomen and beneath ptotic breasts. Constant rubbing together of medial thigh folds can cause areas of chronic irritation and infection as well. Excessive redundant folds of skin and fat can also cause difficulty of fitting into clothing, interference with personal hygiene, impaired ambulation and the potential of psychosocial concerns of a disfigured appearance. Surgical procedures to correct skin redundancy include panniculectomy with or without abdominoplasty (CPT 15831), mastopexy (CPT 19316), upper arm brachiocoplasty (CPT 15836), thighplasty (CPT 15832) and hip-plasty (CPT 15834). Cosmetic and Reconstructive Surgery: For reference, the following definition of cosmetic and reconstructive surgery was adopted by the American Medical Association, June, 1989: Cosmetic surgery is performed to reshape normal structures of the body in order to improve the patient's appearance and self esteem. Reconstructive surgery is performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease. It is generally performed to improve function by may also be done to approximate a normal appearance. Indications Resection of redundant skin and fat folds is medically indicated if panniculitis (ICD-9 729.39) or uncontrollable intertrigo (ICD-9 695.89) is present. Chronic or recurrent skin infections may occur. A large overhanging pannus (ICD-9 701.8) may cause lower back pain (ICD-9 724.2) and interfere with ambulation and personal hygiene. In long standing panniculitis, lymphedema (ICD-9 457.1) and skin abscesses (ICD-9 682.2) may be present. Umbilical hernias (ICD-9 553.1) may be associated with a stretched umbilicus in the pannus. Ventral hernias (ICD-9 553.2) from previous abdominal surgery including gastric partitioning procedures may be present and require repair at the time of panniculectomy and abdominoplasty. In female patients with ptotic breasts after massive weight loss, macromastia (ICD-9 611.1) may be present and associated with postural backache (ICD-9 724.2), upper back (ICD-9 724.1), neck (ICD-9 723.1) and shoulder pain (ICD-9: 719.41). Intertrigo and related dermatitis may also be present. Reduction mammoplasty (19318) is indicated in these patients. If ptotic breasts are not enlarged but consist mostly of redundant skin and fat, mastopexy (CPT 19316) may be performed for males and females. Resection of redundant upper arm and thigh tissue is performed to improve the patient's comfort and appearance. Redundant thigh tissue may extend posteriorly and involve the buttocks and inferior gluteal regions. Procedures: Panniculectomy is the surgical resection of the overhanging "apron" of redundant skin and fat in the lower abdominal area. The redundant skin and fat may continue laterally across the hips and lower back. If this is symptomatic, correction by excision of excess tissue in these regions may be medically necessary (CPT 15834). Umbilical or other abdominal hernias may also be present and should be repaired. If significant folds of redundant skin in fat are present in the upper abdomen and signs and symptoms of functional abnormalities are present, an abdominoplasty (CPT 15831) may be indicated with the panniculectomy. Massive weight loss can cause significant ptosis of the breast (ICD-9 611.8). If medically indicated symptoms and signs of breast enlargement are present in the female patient, a bilateral reduction mammoplasty (CPT 19318) is indicated. Ptosis of the breast in male patient requires correction by subcutaneous mastectomy (CPT 19140) with skin resection and nipple areolar repositioning. Ptosis of the female breast without breast enlargement can be corrected by mastopexy (CPT 19316). In the thigh regions, excessive skin and fat is excised using various incisions to provide for direct removal of the redundant tissue with longitudinal or diagonal incisions extending to and sometimes including the inguinal region. The thighplasties (CPT 15832) are usually performed on the medical surface of the thighs, however, can be continued to the posterior inferior gluteal and buttock regions if indicated. In the arms, a brachioplasty (CPT 15836) is performed via an elliptical excision along the medial border of the upper arm. Documentation: Justification for the resection of skin and fat redundancy following massive weight loss should be documented by the surgeon in the history and the physical, and should be included in the operative note. In the abdomen, this consists of the probability of relieving the clinical signs and symptoms associated with the abdominal pannus, diminished abdominal wall integrity, including back pain, recurrent intertriginous dermatitis, poor hygiene and pressure of hernias. For the breast, it should be based on the presence of macromastia or ptosis in females. For the male patient, the presence of ptotic breast skin and nipples should be documented. Photographs: Photographs are usually taken to document pre-operative conditions and aid the surgeon in planning surgery. In some cases, they may record physical signs. However, photos do not substantiate symptoms and should only be used by third-party payers in conjunction with the patient's history and physical examination. It is the recommendation of ASPS that photographs be taken when the patient is in an upright position. The patient, however, must sign a specific photographic release form and strict confidentiality must be honored. It is the opinion of ASPS that a board-certified plastic surgeon should evaluate all submitted photographs. Position Statement: It is the position of the American Society of Plastic Surgeons that resection of redundant of skin and fatty tissue following massive weight loss is reconstructive when performed to relieve specific clinical signs and symptoms. Surgery to resect redundant skin is performed to relieve clinical signs and symptoms related to abdominal wall weakness and panniculitis; to relieve signs and symptoms when macromastia and/or ptosis is associated with this in female patients; and for male patients with signs and symptoms of ptotic breast skin. The resection of other areas of redundant skin and fat, specifically of the upper arm and thighs, may be indicated for cosmetic reasons. References: Davis, T. S. "Morbid Obesity." Clinics in Plastic Surgery, 11(3):517, 1984. Guerrero-Santos, J. "Brachioplasty." Aesthetic Plastic Surgery, 3:1, 1979. Hallock, G. G. "Simultaneous Brachioplasty, Thorachoplasty, and Mammoplasty." Aesthetic Plastic Surgery, 9(3):233, 1985. Hauben, D. J. "One Stage Body Contouring." Annals of Plastic Surgery, 21(5):472, 1988. Palmer, B. "Skin Reduction Plasties Following Intestinal Shunt Operations for Treatment of Obesity." Scandinavian Journal of Plastic and Reconstructive Surgery, 9:47, 1975. Savage, R.C. "Abdominoplasty Following Gastrointestinal Bypass Surgery." Plastic and Reconstructive Surgery, 71(4): 500, 1993. Zook, E.G. "The Massive Weight Loss Patient." Clinics in Plastic Surgery, 2(3):457, 1975. Prepared by the Socioeconomic Committee approved by American Society of Plastic Surgeons Board of Directors, June, 1996 Teena A [email protected] http://www.angelfire.com/tx5/bbwnomore http://www.picturetrail.com/sassytexasvixen Aol Messenger: Swexan2425 Yahoo Messenger: Skyedancer4u NEVER LET PEOPLE, PLACES, OR THINGS STAND IN YOUR WAY OF FULFILLING YOUR GOALS AND LIVING OUT YOUR DREAMS.

Teena, You are always so helpful and encouraging, not to mention absolutely beautiful! Thank you for all you do for us. Do you know if the Numbers and codes that you include in your letter are universal for all incurance companies or are they specific to yours? I've not begun my Reconstructive Surgery journey yet, but may at some point and I so appreciate your assistance. Thanks! Danielle Lap RNY 8/19/03 278/146 (-132) Goal: 129

Thank you very much for the compliments. The codes are universal. Some doctors tweak them here and there, but they are standard. Good Luck and God Bless. Teena A [email protected] http://www.angelfire.com/tx5/bbwnomore http://www.picturetrail.com/sassytexasvixen Aol Messenger: Swexan2425 Yahoo Messenger: Skyedancer4u NEVER LET PEOPLE, PLACES, OR THINGS STAND IN YOUR WAY OF FULFILLING YOUR GOALS AND LIVING OUT YOUR DREAMS.

1. Takes pictures of every rash, sore, bump, mark, cut and infection you get as a post-op anywhere on your body - you never know where you might want to get skin removed, and mark the pic with the date and how many months post-op and pounds lost. If you go to a surgeon and he submits your info in without photos you will automatically get denied, as they want to see a visual of you and what your medical issues are. Most rashes are visible in photos so take your photos before you treat them with creams and powders. They worse your rash looks the better for photographic purposes. 2. Call your PCP every time you get a rash, sore, bump, mark or infection and ask them to prescribe a cream for you - mine always prescribed medications I had to get filled at Walgreen's keep your receipts and labels in preparation for your letter (see #3). I sent my receipts in with my appeal info, as they wanted proof that I attempted to treat rashes. Most insurance companies want 3-6 months worth of documentation. That means going to a doctor and getting prescriptions for your issues. Please do not just go to the doctor and get a prescription thinking it will be listed in your chart. Get it filled, as you may need copies of it later on for the insurance company. 3. Tell your PCP NOW that when you approach your goal weight, you will be asking him/her for a letter of medical necessity for skin removal procedures, and ask your doctor to document every complaint you have about skin disorders, back pain, neck pain, shoulder pain, joint soreness, numbness, tingling and the like - it will help him/her write a more compelling letter a year down the road. I had letters from every doctor I saw: Dermatologist, Chiropractor, Physical Therapist, OB-GYN, PCP, WLS Surgeon, and Therapist (Shrink) as I wanted to make sure that they knew I had a serious enough problem physically as well as psychologically to see all of these doctors. 4. Take your own photos of hanging skin every 3-6 months, date them, list months out, pounds lost, and any problems the skin is causing. If you feel comfortable get a close family member to take them. My sister took my photos for me. I always took them while I was pulling on the skin so they could see just how far it stretched. I took them in various positions standing, stooping, bending, reaching, kneeling, and sitting down so they could see just how bothersome the skin was in my everyday living. 5. Learn the vocabulary and school the insurance person at the Plastic Surgeon's office in case they don't know - if you are not confident, ask them to let you review the request before it is submitted to insurance. Things to know: plastic surgery is never covered by insurance, reconstructive surgery often is. Elective procedures are never covered by insurance, so make sure yours is listed as medically necessary. Most insurance only consider reconstructive surgeries something caused by trauma or something that you were born with like a cleft palate or lip. Read your policy and get a clear definition of the terms reconstructive surgery and cosmetic for your policy because every insurance company and policy is different and unique. Every insurance company has their own definition so what your neighbor has even though it is the same insurance company it could be a different policy if you work for different companies. She could have exclusions on her plan where you could have none. 7. For you writers, when you journal, highlight the section where you talk about how your loose skin is starting to affect your quality of life, just in case you have to write an appeal letter later, you can look back on these notes to help you draft it. I had to include very personal details of how the rashes, pain, body odor associated with the excess skin was affecting my life. While insurance companies do not care about your emotions, they do have to take notice when medical conditions make it hard for you to carry out your everyday duties. I have severe back, neck, and shoulder pain and it is affecting everything I do. The rashes are so bad that they use cause me trouble walking (thigh lift cured that). I have problems lifting heavy items; I have trouble reaching for things. I can not sit or stand for long periods of time, numbness. You have to list things like that. Those are things that affect quality of life. 8. Never take no for an answer. Read your insurance policy and tear it apart and get a full understanding of what they need for documentation. You should have all of your documentation to show you have the need for surgery so use it. Do not count on your surgeon to do it all. They have other patients besides you and sometimes get sidetracked. Who knows your issues better than you do? Before they send your insurance your letter please read it as many surgeons to not include the necessary info as they hate dealing with insurance and they prefer you to pay cash. When they accept insurance they have to take less cash. Be your own advocate and read your letter before it is sent to be sure the things the insurance company care about are covered. 9. Insurance companies do not care that you have issues fitting into clothes and have to buy larger sizes or that your appearance is disfigured. They care about rashes, infections, back, neck, and shoulder pain, body odor, medications you have used to get rashes and infections treated, and the amount of time you attempted to treat the problems. Most insurance companies require 3-6 months of documentation. Save everything. 10. Document everything. Send it to them yourself and keep the originals as they always have a habit of loosing pertinent information. The main thing is to never give up. Do your research and be armed. Never let your emotions get to you during a hearing or appeal. They do not care about tears. Stick with the medical information. They are money hungry and try to save every cent even if it means you suffer because of their thriftiness. P.S. I originally got tips 1-7 from Nittany and I tweaked them and added more text. Tips 8-10 are completely mine. I will warn you though, some insurance companies have exclusions on reconstructive/cosmetic surgeries period and nothing will work no matter what type of functional impairments you have. I had United Healthcare -EPO my first round and nothing worked. I switched to Independence Blue Cross July 2003 during open enrollment and hit the jackpot. They rock. I know how it works take my word for it. I got all of my surgeries approved because of the tips above and countless hours spent in the library reading medical journals.I also learned first hand from my four month process with United Healthcare -EPO earlier this year only to fight like hell and prove everything and still get denied. Good Luck and God Bless.

Please have the AMOS volunteers post this to the library files. It's awesome and it's answers so many of our questions. Thanks for sharing!

Teena, Thank you so much for posting this. I'm going to print it out for reference when I'm ready for reconstruction. It's invaluable. Lisa 6/24/03 487/265/1??