Need Opinions on PS Appeal Letter....

I was turned down for plastics for several reasons, addressed in my appeal letter. I would like your opinion, please

RE: 4/23/2009 Denial for Panniculectomy Post Gastric Bypass Surgery

 

To Whom this May Concern;

 

I am writing you today in an attempt to appeal your decision to deny me Reconstructive Surgery Post Gastric Bypass Surgery. I would like to address your reasons for denial.

 

• Skin necrosis, recalcitrant to conventional wound healing interventions such as debridement.
• Recurrent skin infections requiring systemic antibiotics. (RECURRENT to be defined as at least 2 incidences in a 12-month period)
• Intertriginous skin rashes or skin ulcerations recalcitrant to local treatment by a dermatologist. (Documentation of consult and treatment required.)

 

Explanation: As a Morbidly Obese woman, I suffered many co-morbidities. One of which was Type 2 Diabetes, which needed Metformin and glipizide to treat, escalating to insulin shots, including but not limited to, Novolin, Novolog, Humulin, Lantus, and Byetta.  Due to the fact that my Diabetes was hard to control for a period of time, I spent a year and a half of my life dealing with weekly yeast infections. The rash, smell, itching and pain left a very emotional scar on me. Once under control, it was not unlikely for me to get yeast infections every month or two.

 

After starting to lose a significant amount of weight, on a routine visit to my Surgeon, I mentioned that under my Panni was at times, itchy, red, rashed, somewhat moist and slimy, and smelled really bad. He looked, and told me it was a yeast infection on my skin, caused by the hanging panni. He told me to treat it with over the counter yeast infection medications, such as Monistat, or antifungal powder to combat the “wetness” and that would clear it up. After what I went through while Obese, I was determined not to go through this ever again, no matter WHERE on my body it was.

 

After an hour of reading labels on packaging in my local CVS, I purchased a powder called Quinsana Plus (Tolnaftate 1%) Powder. Daily use of this powder cleared up the infection, and removed the wetness. Whenever I would start to get that familiar feeling, The powder got put on 3x a day. This kept me from more serious issues such as, Necrosis, Debridement, Bacterial Infections, and further treatment at a Dermatologists office.

    

As for affecting my life day to day, thanks to my bypass surgery, I love the fact that I can run and chase my kids. I hate the fact that if I do not secure my skin, it flaps against me as I run, making it uncomfortable, and making me not want to run or play with my children. I also need to constantly remember to powder the area under my Panni, sometimes twice a day while I am at work, to avoid any infections. The fact that there is the hanging panni skin, as well as the extra skin on my upper inner thighs keeps me from working out to my full potential, for fear sweating will set of another infection, or worse, that I could get any extra skin caught in the weight equipment at my YMCA, which has happened on more than one occasion, causing pinching, bruising and pain.

 

As for hygiene, I have to lift and clean under the panni area thoroughly both morning and night, make sure it is very dry, sometimes using my hairdryer to blow dry the area to remove all traces of moisture, then apply either cornstarch powder, or Quinsana depending on the day and condition of my skin. Also, on several occasions, I have had to wash, dry and powder the area while at work.

 

It has been because of the preventative measures that I have been taking that have kept me from needing dermatological treatment. So according to Tufts, I need to ALLOW my skin to necrocise, need debridement, and be treated by a dermatologist BEFORE granting approval for this procedure?

 

I have done all that I reasonably could to prevent most of the infections that I have had under my panni, and along the inner upper part of my thighs. I thought I was doing what I needed to do to keep my skin healthy so I would not have a problem when it came time to request plastics to remove the redundant skin that I had.

 

I ask that you please grant approval of these procedures based on the information both Dr. Castle and I have provided to you, seeing this as “proof” that these procedures are “medically necessary” to avoid further yeast infections of the skin, and possible necrosis, resulting in skin debridement.

 

Thank You for your Consideration,

 

 

I would change this statement " I love the fact that I can run and chase my kids. I hate the fact that if I do not secure my skin, it flaps against me as I run, making it uncomfortable, and making me not want to run or play with my children."

I think it sounds "too" positive.  I would lead with the negative.  Remember you are telling them how bad this is.  I would simply say,  "I hate the fact that if I do not secure my skin, it flaps against me as I run, making it uncomfortable and painful.  This effects my mobility and makes exercising extremely difficult. " 

Red

Thanks Red..... I changed it, it does look better :)

 

Dawn

I think I would also change this slightly.  "After an hour of reading labels on packaging in my local CVS, I purchased a powder called Quinsana Plus (Tolnaftate 1%) Powder. Daily use of this powder cleared up the infection, and removed the wetness. Whenever I would start to get that familiar feeling, The powder got put on 3x a day. This kept me from more serious issues such as, Necrosis, Debridement, Bacterial Infections, and further treatment at a Dermatologists office."


To something like:

After an hour of reading labels on packaging in my local CVS, I purchased a powder called Quinsana Plus (Tolnaftate 1%) Powder. Daily use of this powder while not curing the problem, did keep it from getting any worse and offered some improvement.  However, the rashes, smell and moisture would always return in spite of applying the powder three times daily.  And, as I said, while this did not cure the issue it did keep it in check.  I consult with my physician and he indicated I was doing all that could be done.

You want to avoid any hint that had you gone to a dermatologist the condition could have been improved.  Otherwise they will tell you to see a dermatologist!

You might also want to remove the word "plastics" in the paragraph that starts I have done all that I reasonably could and insert reconstructive surgery.  Insurance companies will see the word plastics and might automatically reject the appeal.

Good Luck!

Hi Dawn,

I'm not sure I got this from the letter, but how many visits did you make to Dr Castle for yourskin issues and over what amount of time.

The language of many of the plans state that they want documented visits for the panni problems. 

These days, they seem to be concerned about very little else, even though the items you describe are common and a significant issue daily.

The first 4 lines here pretty much sum up what they want (this is AETNA, but most of the other companies are similiar) :

http://www.aetna.com/cpb/medical/data/200_299/0211.html

Drop Miranda in my office a line if you have questions, she's excellent. [email protected].

Best wishes

Hi,

I have dealt with Health Insurance Carriers with my line of work and I was fortunate enough to have a plastic surgeon who employs a claims specialist who is EXCELLENT with dealing with insurance.

So my advice about your letter is to yes, include some personal details about how the hanging skin affects your day-to-day life but to be perfectly honest, the insurance companies really don't care as much about that as they do about the MEDICAL NECESSITY of you having the excess skin/fat removed.

They don't want to hear that you used over-the-counter remedies successfully. They want to hear that you tried them and used them UNSUCCESSFULLY resulting in recurring rashes, intertrigo (skin breakdown), and foul orders that affect both your aesthetic as well as your personal relationships with your spouse (for example). They want you to actually go to the dermatologist. Not hear reasons why you wouldn't go. They want you to try some prescription strength anti-fungal or rash medications and STILL had evidence of the conditions RECURRING.

The bottom line is that you have to convince them that your reasons for requesting surgery are NOT cosmetic. You have to prove (especially after a denial) that you have exhausted all (or at least) most avenues (including customary medical intervention) in an attempt to remedy the problem to no avail. Often times, they want to see that you have evidence of having the problem and having medical documentation that you have been trying with doctor's help to combat the problems over 6 months time or more with little to no improvement and recurring problems.

Finally, letters from your primary care physician, your weight loss surgeon (if applicable), your gynecologist, your dermatologist and/or your chiropractor which outline the issues you have been complaining about, along with their recommendations that you would greatly benefit from reconstructive surgery as a more permanent alternative to relieving your condition would weigh heavily in the insurance company's decision process.

Pictures of rashes, skin breakdown, grooves or skin bruises from bra straps, evidence of skin infection, excess skin that hangs below the mons, hanging breasts that hang to the midsection ( for example) are also very useful to build your case.

I guess what I am saying is that your letter appeals to those of us that know your situation because it's our situation too. But to the bureaucracy of an insurance company's approval team, it's too long on the emotional side and not enough on the medical necessity side.

I hope this helps you fine-tune your letter and get approval.

First, let me say that I can totally empathize with the emotional side of things in your personal life. Unfortunately, as Renee said, the insurer's job is to look at medical necessity.

I worry that the letter, as it is currently written, will not helping your case, but rather, is setting you up for another denial. It sounds as if you are telling them that the OTC meds are working and that you haven't needed to see a derm. If that is the case, despite the fact that having to apply/reapply creams is a bother and it would be more convenient to have plastics, you have to show them WHY you need it, not how you have effectively avoided making the problem worse by effective use of the creams.

good luck to you. I wrote a similar letter for my appeal and was denied again. I'm taking a break and will try again in a few months.