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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.