To Whom It May Concern
 RE: Reconstructive Surgery on Patient Sue Barr  

From my GYN

5/16/01

RE: Sue Barr
To Whom it May Concern:

Sue Barr has had a tremendous amount of weight loss secondary to a gastric bypass.  Because of this weight loss, she has a very significant amount of excessive skin which has caused her several problems.

Gynecologically, this excessive amount of skin has caused significant sexual dysfunction and difficulty in keeping good hygiene. I recommend that she have this excessive skin removed for her health.

Sincerely,

My GYN
Department of Obstetrics & Gynecology

From my PCP

May 31.200l

Re" Susan Barr
To Whom It May Concern

I am writing in regards to my patient Sue Barr. Sue has had a drastic amount of weight lost in the past three years.  Due to this incredible amount of rapid weight loss, Sue has had the health benefits that go along with this, with the exception of one. Unfortunately, Sue suffers from acute dermatitis and yeast in the areas where her skin is hanging due to the excess weight. This medical condition can be corrected with surgery and will benefit this patient greatly. This will decrease the amount of future medical bills that this patient will accrue due to the constant dermatitis and yeast infections.

We would appreciate your considering payment for this surgery.  At this time, the patient will consult with a surgeon who will determine the course of treatment for this fine lady.

If you should have any questions that I may be able to answer, please contact me at 555 - 4200.

Sincerely,

My PCP
Medical Director Board Certified Family Practice

My appeal letter to Aetna concerning their turndown of my arms and legs. 

To Whom It May Concern

Several weeks ago I received a letter telling me that my request for reconstructive surgery had been denied.   As stated in your letter, I was approved for: excision, excess skin and subcutaneous tissue (incl lipectomy) abdomen but declined for: excision excessive skin and subcutaneous tissue, arm (potentially cosmetic). 

I'm having great difficulties understanding this decision and would like to tell you a little more about myself and my situation and hopefully help you understand why the removal of excess skin on my arms and thighs is so necessary.  And although I'm sure you are aware of these publications, I'd like to give you some information that I have obtained from the ASPS (American Society of Plastic Surgeons) website. 

In October of 1998, I had gastric bypass surgery.   I weighed 500 pounds and was dying from morbid obesity.  I firmly believe that this procedure saved my life.  I suffered from many comorbidities.  COPD, sleep apnea, damage to my knees and ankles from carrying so much weight for so many years, chronic back pain, an enlarged heart, fatty liver with abnormal enzyme readings, high blood pressure and depression to list a few. 

At the time of my surgery, I was prepared to die.  I did not care if I lived at all.  I was ready to give up walking as I could not walk from my sofa to the front door without having to stop to catch my breath.  I had to drag a chair to the stove to cook.  I could not stand to wash dishes because of the back pain.   I could not take care of my daily hygiene (toilet and bathing.)  Words alone cannot convey to you the nightmare that I was living on a daily basis.  I was actually jealous of handicapped people in wheelchairs or motorized carts, as they were "acceptable" handicaps.  These people could move freely about in their scooters without getting short of breath.   I was just fat and therefore unacceptable.

As a result of my gastric bypass, within a year I had lost 250 pounds and in two years a loss of 320 pounds.  My weight today is 167 pounds.  I am now able to breathe and move without every motion resulting in excruciating pain or shortness of breath.  I am off all breathing medications, my heart is no longer enlarged and my liver has normal readings.  My labs are wonderful!  Why?  Because of this life saving operation.

Now I want to tell you what living in my body today is like.  While I am proud of my accomplishments, I am ashamed and embarrassed by my body.   The skin on my arms hangs down nearly four inches resulting in a "batwing" look.   I suffer from intertrigo under my arms, sides, breasts, folds of flesh in my thighs and behind my knees.  The skin from my thighs hangs down below my knees.   Despite meticulous care and using many medications (OTC as well as prescription) I find it impossible to stay free of rashes, yeast or fungus infections. 

I am unable to squeeze my arms into clothes that fit because of this excess flesh so I have to wear larger size clothes.  In order to try to keep my thighs from rubbing together I have to wear hose at all times.  While this somewhat helps to "control" the thighs rubbing, it results in yeast infections and rashes in the creases of skin that are folded into my hose.  I live in Las Vegas and with extreme temperatures of 115 plus, this becomes an ongoing chronic problem for me.  If I do not wear hose, I get terrible red rashes that ooze and scab over between my legs.   I cannot kneel because of the excess flesh, sit cross-legged on the floor or comfortably cross my legs.  When putting on panty hose I have to elevate my legs in the air to get the folds of skin and flesh packed into the hose.  I can literally grab handfuls of excess flesh from my thighs.  Because of the skin that hangs down below my knees, I am not able to lift items properly and instead must bend at the waist.   Because of the damage that was done to my spine from carrying 300 extra pounds, I now avoid lifting items that "normal" people think nothing about.  I have to rely on my husband or others to do the lifting for me, sometimes asking help from strangers.

With these constant rashes and infections, my skin smells badly.  I must be careful not to get it caught or drag on things, which results in cuts and bruises.   It is impossible to keep my skin sweat and odor free.  I am meticulous about my personal hygiene, bathe daily and use antiperspirants yet this remains an ongoing daily battle for me.  Some days the odor is uncontrollable.  The excess skin makes it difficult for me to move comfortably.  The weight of my skin causes me fatigue and makes it difficult for me to perform even simple tasks that require holding my arm out at shoulder height.  My arms are so heavy I cannot hold them up for any length of time. This skin also inhibits my range of motion, making it very difficult and sometimes impossible for me to perform normal daily tasks such as putting things away in a high cupboard or hanging laundry on the clothesline.

Then there is the body image issue.  Because of this flesh, hanging and dragging me down I have withdrawn from normal marital relations with my husband.   I cannot stand to see my body without clothes and hate even more for my husband to have to view the horrifying sight of all this skin.  He never sees me dress or undress anymore.  I am too embarrassed for him to see what I have to go through each day.  How can he want to get close to me when I constantly have rashes and odors?   We deserve to have a normal sex life and I am unable to give him that.  I cannot begin to tell you the changes this has brought to our marriage.  I love this man, want to spend the rest of my life with him and give him everything he deserves.   And one of those things is a wife who can get close to him without being ashamed of herself.   While my weight loss has given me a life back in so many ways, I find myself withdrawing from my husband and don't like it!

And now some information from the ASPS site. 

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

And from Aetna U.S. Healthcare's Coverage Policy Bulletin #31

Aetna U.S. Healthcare does NOT cover cosmetic surgery except in the limited circumstances outlined below.

Reconstructive surgery is performed to improve or restore bodily function and is generally eligible for payment. The correction of severe congenital anomalies is covered subject to a review of the reasonableness of such procedures.

The following procedures are nearly always cosmetic in nature. As such, they are not covered except when a case specific review justifies a medical exception:

Excision, excessive skin, thigh, leg, hip, buttock, arm, forearm or hand, submental fat pad, other areas (CPT-4 Codes 15831 - 15839).

Based on the information from your website, as well as the information from the ASPS, I am requesting a medical review.  My reconstructive surgeon, Dr. Stephen Weiland will soon be submitting another request for me to have this surgery.  

I have enclosed some Ziploc bags.

I. With water, fill these gallon size bags about halfway.
2. Tape one bag to each arm, so that it hangs about 4 to 6 inches from the back of each arm.
3. Tape one just under the breast, so the bottom of the bag hangs just above your belly button.
4. Tape a bag to each cheek of your buttocks. The bottom of the bag should hang just where your buttocks ends and your leg begins.
5. Tape two bags to each knee. One on the front and one on the back. On the front, the bottom of the bag should  hang right on top of the knee bone. On the back, the bottom of the bag should hang about 3 inches below the joint.

Now you have an idea of how my body is.  I want you to imagine under your arms, buttocks, and between your thighs, you have constant irritated rashes. You have a rash in your armpits and on the sides of your body.  On your buttocks is an annoying rash where the skin folds, as well as a rash behind your knees. In all of these places, there is excessive perspiration, which no air can get to. Now toss in a terrible body odor. All of these issues are good medical reasons to remove my excess skin.

Now just think about trying to put clothes on over all of this. Try to get dressed juggling this flesh around, stuffing it into your clothes.  Imagine you are a size small and petite, and are forced to wear size large in order to accommodate your arms and legs.

Now I would like you to jog in place. Remember your skin has sores on it. Your thighs are moving and pulling with each motion.  It hurts, just as your arms do.  

Imagine having sexual marital relations with your spouse. First, you keep the lights off because you are ashamed, you smell bad, and you have to move your thigh skin out of the way.   Surely doesn't create a positive atmosphere for many romantic moments and intimate moments, does it?

I am 45 years old and have many ambitions in life.  I would like to be active and participate in many sports, but hesitate because of these rashes and the skin hanging.  I cannot go to any outdoor water park without people thinking I am a freak. They actually point and stare at me when I make the mistake of lifting my arms or wearing shorts in public.  Just think about wearing panty hose, long slacks or long sleeve shirts when you live in the desert with temperatures that go higher than 115 degrees.

These are only a few examples of things that deal with the quality of my life as it is now.  As you make your decision, please remember that you are making a decision that will profoundly affect my life and relationship with my husband and others.   The facts of medical necessity are plain, and the need cannot be disputed. I also ask that you take into account the very personal issues as well as the psychological needs.  

You should also have on file letters from my primary physician Dr. Ronald Hedger, my gynecologist Dr. Richard Litt and my Bariatric surgeon Dr. Barry Fisher.  If you do not have these letters, I would be more that glad to send them to you. 

Thank you for your consideration and I do hope and pray for a positive reply.  

Sincerely,
Sue Barr

From my Plastic Surgeon to the Insurance Company

June 12, 2001

To Whom It May Concern:

Susan Barr is a patient I saw recently for evaluation on 5/14/01.   She has a remarkable story of having had a gastric bypass, which was very successful for her and has lost between 200 and 300 pounds.  She has a lot of loss of tissue and loose skin on her arms, chest, abdomen, inner and outer thighs.  The problems with the inner and outer thigh skin is that it causes rubbing and irritation to these particular areas, as well as problems of rubbing and irritation from the extreme amount of loose skin from the are of the arms.  She had her previous initial panniculectomy, but she has lost more weight since that period of time and continues to have a pulling down on her abdomen and waist from this extra tissue, as well as laxity of the area of the thighs.

I feel this patient probably needs a staged reconstruction in order to help her.  The first thing I think we could potentially do, however, would be a truncoplasty where we do a lateral abdominal lift, as well as anterior abdominal lift, and consider doing an arm lift at the same time.   I think this would be a reasonable amount of work to be done as a result of her enormous amount of weight loss.

Enclosed you will find pictures of her at this time.  I am sure you are as impressed as I am with her tenacity in being able to lose this weight and we all wish her the best.  Below, you will find the estimates for the planned surgery.   Also enclosed please find copies of letters from other physicians the patient has seen and who have recommended this surgery be carried out.  If you have any questions, please call.

CPT code #15831 (truncoplasty) - $8495
CPT code #15836 (arm lift) - $3095

Sincerely,

Stephen W. Weiland, M.D.

July 27, 2001

To Whom It May Concern:

Susan Barr is a patient I recently evaluated.  She has had enormous success in losing between 200 and 300 pounds.  I understand that her truncoplasty is covered, however the brachioplasty is not covered based upon your specific criteria.   As you can see from the pictures, there is breakdown of some of the skin on the inner and outer thighs, but the area I am most interested in at this point would be the arms.  She had an enormous amount of weight loss to her arms and I think that this is a special consideration that would be something you would want to reconsider, as it is not a usual situation that someone has lost 200 to 300 pounds and keeps it off successfully.   Imagine if you had one-gallon water bags tied to your arms and tried to put your clothes back on and off.  This is an unusual situation, which is quality of life and basically a medical necessity as opposed to a cosmetic appearance per se.

I ask you to reconsider this matter based upon this.  When we do the truncoplasty, we would hope to be able to get the brachioplasty, or the arm lift, done at the same time so that she would not have to undergo but a minimal number of surgeries.   Unfortunately, her surgery is scheduled for August 9, 2001 and I would like to have a response by that period of time so that we will know whether this could be considered or not.

I thank you again for your attention to this matter.  I myself being a plastic surgeon am very comfortable with brachioplasties not be considered in usual circumstances, however, I fell this is a very unusual circumstance and this would benefit her greatly on a medical needs basis and not specifically on a cosmetic basis.

Sincerely,

Stephen W. Weiland, M.D.

September 10, 2001

To Whom It May Concern:

Sue Barr is a patient of mine who recently had a truncoplasty to try to reduce the enormous amount of skin as a result of substantial weight loss from 500 pounds to 165.  Currently, she still has a lot of laxity to the skin underneath her arms as well as the area in the groin.  She has had fungal infections as a result of problems related to this and she has also had problems with normal hygiene and shaving underneath her arms causing problems with razor burns. 

Enclosed you will find pictures demonstrating this.  I feel that she would benefit from surgical reduction of the inner thigh, as well as the arm itself.   She is anxious to proceed on with this and I feel that she is an excellent candidate on the basis for medical necessity.

If you have any questions, please don't hesitate to call.

Sincerely,

Stephen W. Weiland, M.D.

From the External Review considering my final appeal

Dear Ms Barr:

Attached please find the expert review report for the external review request for surgical removal of excessive skin and subcutaneous tissue around the arms and thighs.  Also included is a summary of the expert's qualifications for your review.   The reviewer concluded that the surgical removal of excessive skin and subcutaneous tissue around the arms and thighs is not cosmetic.  If you have any questions, please contact Aetna US Healthcare.  We have also forwarded a copy to them.

Summary of Expert Qualifications
Review #S006

Received a BA from Yale University, New Haven, CT; MD from the University of Alabama, AL.  Completed internship and residency in general surgery and residency in plastic and reconstructive surgery at Yale University School of Medicine, New Haven, CT   Also completed postdoctoral fellowships in molecular biology and in craniofacial surgery.  Is board certified in surgery and plastic surgery.  Currently serves as Assistant Professor of Surgery, Co-Director of the Craniofacial Center, and Director of Education, Section of Plastic Surgery, Department of Surgery, at a well-known northeast university affiliated school of medicine.  Is active in research and is the recipient of numerous professional honors and awards.  Has done scientific presentations and is published in peer-reviewed literature.
Sincerely,
Senior Case Review Manager

Summary of Clinical Case Information

The patient is a 45 year old woman with a large abdominal pannus following a gastric bypass.  She has lost between 200-300 pounds and has overhanging excess skin and tissue from the arm and thighs with resultant intertriginous rash as claimed by her physicians as well as patient.  The appropriate ICD-9 codes for this includes:

Questions to be addressed by this review:

The following definition of cosmetic and reconstructive surgery was put forth by the American Medical Association in 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 but may also be done to approximate a normal appearance.

Weight loss following gastric bypass procedures often result in significant folds of redundant tissue leading to areas of intertrigo which may result in skin infections.  Affected areas usually include abdominal wall and thighs and arms as well as breast.  Impaired ambulation and interference with hygiene can also be seen.

The physician-patient has included documentation of the significant skin laxity and redundant folds of skin by photographs of the patient.  The photographs demonstrate that the patient has intertrigo.  The physician office notes and patient letter document intertrigo.

This patient's condition warrants medical corrective surgery to deal with intertrigo and results following surgery for morbid obesity.  Long-term health consequences may develop as a result of longstanding skin problems.

References:
1.  Davis, T.S. "Morbid Obesity."  Clinics in Plastic surgery, 11(3):517,1984
2.  Palmer, B.  "Skin Reduction Plastics Following Intestinal Shunt Operations for Treatment of Obesity."  Scandinavian Journal of Plastic and Reconstructive Surgery, 9:47, 1975
3.  Savage, R.C. "Abdominoplasty ;Following Gastrointestinal Bypass Surgery."  Plastic and Reconstructive Surgery, 71(4):500, 1993.
4.  Zook, B.G.  "The Massive Weight Loss Patient."  Clinics in Plastic Surgery, 2(3)457,1975

From a doctor to insurance company for skin removal

Board of Trustees Re: My patient

As a physician I have treated my patient for various injuries and pain related conditions, several related directly to her problem of being over weight.

The patient stated that since her gastric bypass surgery she has lost hundreds of pounds and is now able to do so many things that have enriched her activities with her family. Now that she has had the surgery and Corporation has confirmed the necessity for the removal of the massive excess skin, which is a conformation of what the other medical surgeons have stated, and then you as an insurance company have the audacity to refuse the further necessary treatment.

During a consultation the patient complained of infection caused by the overhanging skin, rashes, and sores that are slow the heal, poor circulation and sensory perception of the loose skin, the feeling of areas being swollen and uncomfortable, the lose skin causes odor, and that she must be careful constantly to protect the flabby skin from catching and dragging on things. The folds being impossible to keep disinfected and sweat free. The excess skin makes it difficult to move comfortably. The added unnecessary weight of this skin causes fatigue and adds unwanted resistance when trying to perform even simple tasks that may require holding her arm out at shoulder height.

According to the book "Guides to the Evaluation of Permanent Impairment", written by the American Medical Association, the function of the skin include, QUOTE:

I. Providing a protective body covering,           
2. Participating in sensory perception, temperature regulation, fluid regulation, electrolyte balance, immunobiologic  defenses and resistance to trauma; and
3. regenerating the epidermis and it's appendages.

The protective functions include for example, barrier defenses against damage by chemical irritants and allergic sensitizers, invasion by micro-organisms, and injuries by ultraviolet light. Temperature regulation involves the proper function of the small blood vessels and sweat glands. The barrier defense against fluid loss is related to the intactness of the stratum corneum.

Immunobiologic defenses of the skin prevent and control infection by bacteria, viruses, or fungi. Alteration of skin sensory perception include pruritus, the decrease or loss of sensation, and hyperesthesia, Cutaneous and systemic disorders can alter one or more of these functions. An established deviation from normal in any of the functions may result in a anatomic or functional abnormality or loss and constitute a permanent impairment.

Permanent impairment of the skin is any anatomic or functional abnormality or loss including an acquired immunologic capacity to react to antigens that persists after medical treatment and rehabilitation, and after a length of time sufficient to permit regeneration and other physiologic adjustments. Evaluation of impairment is usually possible through the exercise of sound clinical judgment based on a detailed medical history, a thorough physical examination, and the judicious use of diabmostic procedures.

In the evaluation of permanent impairment resulting from skin disorder, the actual functional loss is the prime consideration, although the extent of cosmetic or cutaneous involvement may also be important. Pruritus is frequently associated with cutaneous disorders It is a subjective, unpleasant sensation that provokes the desire to scratch or rub The sensation is closely related to pain, in that it is mediated by pain receptors and pain fibers when they are weakly stimulated.  However, the itching sensation may be intolerable Like pain, it may be defined as a unique complex made up of afferent stimuli interacting with the emotional or affective state of the individual and modified by that individual's past experience and present state of mind.

The sensation of pruritus has two elements, peripheral neural stimulation and central nervous system reaction, which are extremely variable in make-up and in time. The first element may vary from total absence of sensation to an awareness ofstimuli as either usual or unusual sensations The second element is also variable and is modified by the person's state of attentiveness, past experience, motivation at the moment, and stimuli such as exercise, sweating and changes in temperature.

In evaluating pruritus associated with skin disorders, the physician should consider how the pruritus imerferes with the individual's performance of the activities of daily living, including occupation; and to what extent the description of the pruritus is supported by objective skin findings Subjective complaints of itching that cannot be substantiated objectively may require specialized referral.

Disfigurement is an altered or abnormal appearance This may be a alteration of color, shape, or structure, or a combination of these Disfigurement may be a residual of injury or disease, or it may accompany a recurrent or ongoing disorder.   With disfigurement there is usually no loss of body function and little or no effect on the activities of daily living.   Disfigurement may produce either social rejection or impairment of self-image, with self-imposed isolation, life-style alteration or other behavioral changes, If, however, impairment due to disfigurement does exist, it is usually manifested by a change in behavior such as the individual's withdrawal from society

The possibility of improvement in the altered appearance through medical or surgical therapy, and the extent to which the alteration can be concealed cosmetically should be described in "Titing and should be depicted with photographs if possible END OF QUOTE

The patient, and her physicians, and Corporation, have followed the necessary criteria to evaluate my patients medical situation in order to substantiate the necessity of surgery as a means to prevent future serious conditions

Considering the information from, "Guides to the Evaluation of Permanent Impairment", and my own studies in similar cases, and my knowledge of my patient's condition I submit as my professional opinion that without the improvement that can come through surgical therapy my patient will experience this obvious prognosis.

The condition of Cellulitis, phlebitis, and ulcerations will gradually progress in severity. Once the condition has taken hold, diligent medical care will be required indefinitely. Exacerbation of skin infection and eventually disease, related to deterioration of cellular break down due to poor circulation and injury to the large flaps of skin will require confinement and hospitalization.

The skin eruption will become chronic dermatitis that will require constant treatment by a physician. These will be characterized by a pruritic, red papular eruptions, that will spread to most of her body, followed by scaling and dryness with few, if any, periods of complete remission from the rash, pain, "burning" and itching.

At present, my patient has a 48% total body permanent impairment. As the condition progresses the future prognosis of the illness will culminate to an 80 to 95% total body permanent impairment. 

The individual's mental and physical status and behavior must be considered. Motivation for improvement is a key factor in the outcome. Consider the relationship of the behavioral improvement the surgery will have as it relates to the individual's family, education, financial, social situation and occupation, in comparison to the individual's existing otherwise destined level of dysfunction.

The gastric bypass surgery should be treated no less lightly than any other surgery that requires follow up treatment and rehabilitation. This condition cannot be rehabilitated without the surgery. This is not a short term, self-limiting illness that is going to go away without the surgery.

My patient has been coping well with her present condition only because she has had the confidence that, because of the corporation Statement, when she progressed to a given weight loss the excess skin would be removed. Considering my patient's financial condition it will be necessary for her to rely on her husbands insurance to cover the cost of the skin removal of all the excess skin that has resulted from her gastric bypass and weight loss. This will include the skin from her arms,, legs, breasts, buttocks, and stomach.

This surgery is considered to be usual, customary, and necessary for the continued improvement of a patient following gastric bypass surgery .This is not to be considered cosmetic surgery, such as breast implantation, change in nose size, or wrinkle removal, and there is no medication or exercise that can improve my patient's condition. Total rehabilitation will be dependent upon this surgery which is necessary for the prevention of adverse conditions, and for the future recovery of my patient's mental well being as well as her physical health.

If you have any questions please feel free to call me at my office.

Dr. Doctor

Letters sent to the insurance company to get approval for Panniculectomy and/or Abdominoplasty.

(Courtesy of Donna Nave)

The initial information sent to the insurance company was sent from my Doctors office.  The only thing sent was a letter requesting approval for benefits for a hernia repair and Panniculectomy surgery.  They did approve my hernia repair but not my Panniculectomy/Abdominoplasty.

LEVEL I GRIEVANCE

This is the first letter of Appeal that I sent the Insurance Company.   The insurance company also requested copies of my medical records relating to my back pain and rashes.  It is much quicker if you get these records yourself.  I also sent in pictures of my apron.  Front view, side view and back views.

Dear Sir:

Please accept this letter as "Notice of Appeal."  In your letter dated July 1, 2000, you denied my proposed  Panniculectomy/Abdominoplasty procedure, by Dr. Steven Olchowski, however you approved the repair for a ventral hernia.

Once again, let me say I was NOT requesting the Panniculectomy/Abdominoplasty for "Cosmetic Reasons."  I had Roux en Y Gastric Bypass on March 23, 1999, and to date have lost 100 pounds.  I require help for reconstruction of a large Panniculus, (apron of fat and tissue) causing me severe back pain and for medical complications with repeated infections under the Panniculus, which is considered a medical necessity.

Definitions:  Abdominoplasty is defined as a surgical procedure, which tightens a lax anterior abdominal wall and removes excess abdominal skin.  It may be reconstructive or cosmetic.

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, but may also be done to approximate a normal appearance.

Abdominoplasty is considered reconstructive when performed to correct or relieve structural defects of the abdominal wall (ICD-9: 701.8/708.9) and/or chronic low back pain (ICD-9: 724.1) due to functional incompetence of the anterior abdominal wall. These conditions may be caused by:

Permanent overstretching of the anterior abdominal wall following one or more pregnancies; (ICD-9: 701.8.701.9). (I have had one pregnancy.)

Permanent overstretching (with or without diastasis recti (ICD-9: 928.84) of the anterior abdominal wall with a large or long abdominal panniculus (ICD-9: 278.1) following weight loss in the treatment of morbid obesity (I had RNY gastric bypass surgery, which BC/BS approved and paid for in March of 1999.) and resulting in the uncontrollable intertrigo (crease dermatitis, ICD-9: 692.9) and/or difficult ambulation (ICD-9 724.8). (I frequently get the intertrigo and crease dermatitis as referred to here.   Your records should show that for over a year now I have been using TRIAMCINOLONE.1% EUCERIN cream to treat this which is available only by prescription.)

Trauma or surgery to the anterior wall of the abdomen resulting in loss of muscle of fascial integrity or pain from scar contracture (ICD-9: 709.2).  (Once again, the gastric bypass surgery meets this criteria.  My gastric bypass required me to be opened from my breastbone to just past my navel.  I have also had a total abdominal hysterectomy and two other abdominal surgeries.)

Abdominal hernia following previous abdominal surgery (ICD-9: 553.201, 553.21).  (A ventral hernia has been noted and confirmed by test.  This will need to be corrected and has been approved by BC/BS.)

Panniculectomy is performed to relieve the massive apron of fat, is considered purely functional and therefore should be covered by my insurance policy.   (Which I have attached pictures and my Doctors office also has sent pictures.)

Abdominal dermolipectomy has been performed since the turn of the century. In the United States, H.A. Kelly called attention to this procedure and its positive outcomes (weight reduction, personal comfort, convenience and  comfort in dressing, better pose in standing and walking, increased activity and greater ease in hygiene) in his 1910 publication

Abdominal wall pathophysiology concerns weakness or laxity of the abdominal wall musculature.  An excess of ten pounds of adipose tissue in the abdominal wall adds 100 pounds of strain on the disks of the lower back by exaggeration of the normal "S" curve of the spine.

Cosmetic Abdominoplasty:
When an abdominoplasty is performed solely to the enhance a patient's appearance in the absence of any signs or symptoms of functional abnormalities, the procedure should be considered cosmetic in nature.

It is the opinion of the ASPS that a cosmetic abdominoplasty is not a commendable procedure unless specified in the patient's policy.  (I'm not requesting this procedure for cosmetic or aesthetic reasons.) 

As you can see my situation meets the requirements for medical necessity.

Position Statement:

It is the position of the American Medical Association, American Society of Plastic Surgeons, the position of Dr. Olchowski, and myself, that abdominoplasty, including repair of diastasis recti and panniculectomy, is reconstructive when performed to relieve specific clinical signs and symptoms related to abdominal wall weakness and panniculosis.  Clearly, I meet the criteria for reconstructive Panniculectomy/Abdominoplasty.

Sincerely,

Donna Nave

References:
Bozola, A.R. Psillakis J.M. "Abdominoplasty: A New Concept and Classification for Treatment", Plastic and Reconstructive Surgery, 82:983, 1988
Floros, C., Davis, P.K. B., "Complications and Long-tern Results Following Abdominoplasty: A Retrospective Study", British Journal Plastic Surgery,44:190, 1991
Gracovetsky, S. Farfan, H., Helleur, C., "The Abdominal Mechanism," Spien 10:317, 1985
Hester, T., Roderick: Baird, Wilbur: Bostwick, John III: Nahai, Foad: Cukic, Juliana. "Abdominoplasty Combines with Other Major Surgical Procedures: Sage or Sorry?" Plastic and Reconstructive Surgery, 83:997, 1989
Kelly, H.A. "Excision of Fat of the Abdominal Wall - Lipectomy", Surgical Gynecology and Obstetrics, 10:229, 1910
Toranto, I. Richard. "The Relief of Low Back Pain with the WARP
Abdominoplasty: A Preliminary Report", Plastic and Reconstructive Surgery, 85:545, 1990.
Toranto, I. Richard. "Resolution of Back Pain with the Wide Abdominal rectus
Plication Abdominoplasty", Plastic and Reconstructive Surgery, 81:777, 1988.

LEVEL II GRIEVANCE 

    I WAS APPROVED AFTER THE INSURANCE COMPANY RECEIVED THIS LETTER AND THE LETTERS OF MEDICAL NECESSITY FORM MY DOCTORS I SENT WITH IT.  ~~WOOO   WOOO~~

By now I have gone through what seems like 1000 phone calls.  I received a letter stating that I am DENIED and everything is going to level II.   Well, the reason I was denied was not enough documentation (recent) of my rash.   So I stopped using my medicine and went to the Doctor.  I send another short but nice letter to the insurance letter to BC/BS along with 2 letters from my Doctors.  One from my primary care Doc and the other from my Dermatologist stating "medical necessity" for the Panniculectomy/Abdominoplasty.  Here is my Second letter.

Dear Ms. Lee:

Please accept this letter as "Notice of Appeal."  In your letter dated August 17, 2000, the Level I Appeals Committee denied my proposed  panniculectomy/abdominoplasty. 

Along with the information I have already submitted to you, (copies of medical records, letter of medical necessity from Dr. Olchowski, and preoperative photographs).  I am now submitting two letters of medical necessity.  The first letter is from Dr. C. Daum, which is my primary care physician.  Dr. Daum states in her letter that it is a medical necessity for me to have a panniculectomy/abdominoplasty.   The second letter is from Dr. L. Tanner.  Dr. Tanner is my Dermatologist.   Dr. Tanner has been treating me for intertrigo for several years, as you can see from my medical records.  The reason I have not had any recent visits to her was because I have been using a cream to suppress the rash and just having the pharmacy call for refills.  I did stop using the cream and in just a few days the rash was full blown again.  I did go and see Dr. Tanner at that time for documentation and treatment.  As you can see from her letter, Dr. Tanner clearly states that a panniculectomy/abdominoplasty is a medical necessity.

Once again, I am NOT requesting the panniculectomy/abdominoplasty for cosmetic reasons.  I require help for reconstruction of a large Panniculus.  Reconstructive surgery is performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease.  I have had several abdominal surgeries causing trauma to my abdomen.  I have had a Gastric Bypass and lost over 100 pounds causing the extra large apron and I have the infection and disease in the creases of the skin.

As you can see my situation meets the requirements for medical necessity.   With the information I have already submitted and the two letters of medical necessity I am sending you today, I feel that I have proven that the Panniculectomy is reconstructive and is a medical necessity.

I am having my hernia repair on September 28, 2000, at New Hanover Regional Medical Center.  I would like to have the Panniculectomy/Abdominoplasty done at the same time.  Instead of having two separate surgeries and two separate hospital stays this will be only one if I can have them together.  Please contact me if you have any questions.

Sincerely,

Donna Nave

Here is a copy of the letter from my Dermatologist.

Dear Ms. Lee:

I am writing on behalf of my patient, Donna Nave, who suffers from chronic erosive intertrigo.  This has greatly improved since she got her gastric bypass and her body folds were dramatically reduced. She no longer gets it in her armpits, her sides, or under her breasts, but due to the large Panniculus that has formed secondary to extreme weight loss, the area just under the abdomen is afflicted.

I examined her today and there is a large, red, oozing plaque that smells of yeast and is eroded on the surface.  This is extremely tender to touch and smaller plaques of the same description can be found on the groin creases. Unfortunately, this type of intertrigo is a mechanical problem, which is only alleviated by air. A simple Panniculectomy can take away the fold that traps the moisture which grows the candida.

I hope that this letter of support of medical necessity for the Panniculectomy will succeed in getting the procedure for my patient.

Sincerely,

Laura S. Tanner, MD

Appeals Committee Your Insurance Co.
Address
 

Dear Appeals Committee:

On November 17, 1998 this company allowed me to begin a journey back to health.  This letter is an appeal of a denial for an abdominoplasty I received.  Two years ago I was the recipient of gastric bypass surgery.  At over 400 lbs. this was a life saving procedure.  I am requesting now that I be able to be completely healthy.  I have over many years had a number of abdominal surgeries, which include 2 cesarean sections, a hysterectomy and the gastric bypass.  The result of all this has been a lot of skin that hangs from my stomach and upper thighs.  This skin hangs down past my pubic area and you received a Polaroid picture with the original request for surgery.  My lower back hurts me to the point that I must sit down to relieve the pressure.  I also have a very embarrassing problem with "yeast-like" rashes and boils that break out under the skin fold on my stomach.  This is very painful and I have to be extremely diligent in keeping these from becoming infected.  During my research into the abdominoplasty I have found that I meet every requirement set out by the American Board of Plastic Surgeons (ABPS). 

The ABPS states, "Reconstructive surgery is performed on the abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease.  It is generally performed to improve function, but may also be done to approximate a normal appearance." 

As stated above I have severe lower back pain, and rashes.  The weakening I have experienced in my abdominal muscles is the reason for my back pain.  I also have a visceral hernia as a result of poor healing of my gastric bypass incision, which you have already approved the surgery to fix.  The ABPS gives a general listing of what is considered reconstructive for an abdominoplasty including:

• Chronic Low Back Pain  ICD-9:724.1        

• Permanent overstretching of the abdominal wall  ICD-9:701.8,701.9

• Overstretching with a large or long abdominal  panniculus  ICD-9:278.1

• Trauma or surgery to the abdomen with muscle  weakening  ICD-9:709.2

•  Abdominal hernia following previous abdominal  surgery  ICD-9:553.201

•  Following weight loss in the treatment of morbid obesity resulting in uncontrollable intertigo
   ICD-9:692.9
   

You will find included with my letter three other letters from board certified physicians that also state that this procedure is medically necessary reconstructive surgery for me and not plastic surgery.  You will also find enclosed the statement in full for the ABPS.  I have never nor will I ever look like a super model.  I don't want that, what I want is to be able to live life pain free and infection free.  I have almost completed this journey and now that I find myself very close to the end I have run across one of life's many stumbling blocks.  This letter is a result of that stumbling block; your attention to this matter in a timely fashion would very greatly be appreciated.

Sincerely,
Your Name

This letter is to request contract benefits for a panniculectomy.  Please be aware that this surgery is not being performed for cosmetic reasons.  The patient has experienced massive weight loss (129 pounds) since her bariatric surgical procedure in 1994.  As a result of this weight loss, she has developed a huge pannus that hangs from her abdominal wall, causing underlying lax abdominal musculature. 

Because there is so much tissue hanging down anteriorly, the patient experiences chronic low back pain because she must bend over backward to maintain balance.  The lordosis causes disabling back discomfort. This has forced Mrs. Smith to seek temporary relief through frequent chiropractic manipulations. Also, when trying to exercise, the heavy panniculus hits her thighs; this is painful enough to cause her to discontinue exercising.

The scarring from previous abdominal surgeries exacerbates the demarcation line, and increases the severity of the panniculus droop.  The progression has causes degenerative changes in her hips. She also suffers from spinal degeneration which is heightened by the excess weight in her hip region.

Also of distress to Mrs. Smith is the intertrigninous dermatitis in the supra pubic crease, caused by the fact that the overhanging skin is never exposed to the air.  It is chronically moist. Bacteria grow there, they cause a foul odor and the intertriginous dermatitis results. She has had numerous seborrheic keratoses and skin tags surgically removed, due to the constant moistness of the area.  In spite of powders, antibiotic creams and frequent bathing, the odor from the overhanging skin is a social problem for the patient, and there is considerable tenderness of the skin in the area.  There is an odor present that is very unpleasant, which causes her social embarrassment while she works with the public as a volunteer and part-time employee in the public sector.

The only therapy that will resolve this problem is to amputate the excess skin, thus exposing the atrophic skin to the air. Within a few weeks, the dermatitis will disappear entirely. 

It is my professional opinion that her chronic lumbosacral pain will be markedly improved, if not relieved entirely, by amputating the pannus; and her intertrigninous dermatitis will be cured by the removal of the skin. This, in my mind’s eye, justifies performing the procedure because it will reduce her disability related to her back and it will markedly improve the quality of her life because of the odor that is continually present as a result of the intertrigninous dermatitis.

Many insurance companies are beginning to cover surgeries that were formally thought of as cosmetic because they realize that, as in breast reduction surgery, the patient has a legitimate physical malady. Breast reduction has long been well accepted as a covered benefit by most insurance companies for a patient that meets their criteria; the most usual criteria being one pound or more of excess tissue per breast, causing back pain or intertrigninous dermatitis.  This patient will most often be relieved of back pain and dermatitis with the removal of only two pounds of tissue.

When weighing the tissue removed by panniculectomy, we commonly find it weighs three to seven pounds, sometimes up to thirteen pounds.  It is easy to imagine that if the removal of two pounds of excess tissue can relieve back pain, the removal of a larger amount could only have at least the same effect,. To a corresponding degree, the breast reduction patient also receives the cosmetic benefit of looking more like the average woman in our society.  Most insurance does not deny the breast reduction due to the fact that the patient receives a cosmetic benefit of a normal appearance.

The panniculectomy patient that experiences back or joint pain and chronic dermatitis should not be denied relief from his or her pain and discomfort for the very same reasons that a breast reduction patient is not denied relief.  The fact that the surgery will also allow the panniculectomy patient to have a more normal appearance is an added benefit.

I am writing this to request your reconsideration of the decision made on 10-07-99 in which benefits for an abdominoplasty were denied for myself.  I am dismayed by this denial because the purpose of the request was apparently misunderstood by the medical board. This surgery was necessary to help resolve several medical problems and was not requested for the sake of appearance or for cosmetic purposes.

By fall of 1999 I had developed a marked excess of abdominal tissue in the mid-to-lower abdomen which resulted from a 125 pound weight loss since bariatric surgery on Aug 4 1998. Following my bariatric surgery, the chronic low back pain that I had experienced prior to the Aug 1998 surgery initially improved, but became more constant and severe with the development of the redundant abdominal tissue resulting from the weight loss. The increasing low back pain was diagnosed as severe chronic low back strain associated with hyperlordosis of the lumbosacral spine caused by the downward and forward pulling on the low back by the heavy redundant abdominal tissue. A variety of conservative measures were unable to resolve this condition.

Additionally, I was unable to obtain relief of a painful intertriginous dermatitis of the lower abdomen and groin regions caused by the accumulation of moisture and heat caused by the redundant tissue overhanging in this area. Topical anti-inflammatory and antimicrobial agents failed to appreciably improve this condition, despite scrupulous hygienic measures. This condition was further aggravated by urinary stress incontinence that was worsened by activity due to the excessive abdominal tissue pulling on the urethra. Prescribed Kegal exercises and other conservative medical treatment failed to resolve this condition.

Furthermore, I suffered from severe balance and coordination problems as a result of the swinging and bouncing motions and momentum of the redundant abdominal tissue, which resulted in multiple injuries from bumping in to walls, corners, furniture, etc. The high risk of serious injuries from the sudden changes in center of gravity caused by the motion of the redundant tissue was particularly evident when going down stairs or escalators.

It was the professional opinions of my surgeons in that these problems should be addressed at the time I was admitted (Nov 2,1999) to relieve the symptoms associated with a dilated atonic gastric pouch and outlet. In summary, let me emphasize to the medical board that this procedure was not in any way cosmetic. Please consider approval for this procedure as it was medically necessary and has already significantly improved the aforementioned medical conditions.