raine918

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