Need help with Letter of medical necessity for State Appeal

OK,, Need your help from all of you out there,,,, I have been denied on appeal fro my panni and thigh lift. Here is the letter I sent for appeal,, need help "beefing" it up so that I can send it off to Massachusetts state office of patient protection, for a FINAL appeal.

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, 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 affects my mobility and makes exercising extremely difficult. 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,

  

Any help you can give me would be greatly appreciated !!!  Also - if anyone has a picture of what a rash under the panni looks like,, it would help, so that when I let one develop,, I know what it is and can take good pictures of it to go to the state.

Dawn

Dawn-
It is a good letter, however I have some thoughts on a couple of changes.

Red

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.

 

How about:

Per my physician’s instructions I purchased Quinsana Plus (Tolnaftate 1%) Powder. Daily use of this powder while offering some control of the issue, hardly cured it. The rash and moisture would show some improvement but it never completely went away. In spite of using the powder three times a day the infection flares up every couple of weeks. Frankly, according to the conversation I had with my physician, I felt I was doing everything possible for this condition and that treatment by a dermatologist would have amounted to what I was already doing, i.e. applying the antifungal powder and trying to keep the area dry. It has only been due to my diligence that the condition has not progressed further. Yet, I feel that my skin has been severely damaged as a result of this on-going issue. Not to mention the constant pain and itching. Plus the problems with the odor has effected me emotionally. When I can smell my skin, even when fully clothed, I never feel truly clean, nor am I comfortable being around people. I am very self conscious as it is a constant worry that I may smell offensive to others.

 

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.

I would change the above to leave out the names of the medications. Since you are stating that the doc told you to use Monistat and then you used something else. You also want to reinforce that you were following doctors orders and doing everything you were told to do.

 

When I had lost a significant amount of weight, I told my surgeon that the area under my pannus had a strong odor, an itchy, red, rash, and was moist to the point of feeling sticky and slimy. He examined the area and told me it was a yeast infection on my skin, caused by the hanging pannus. He explained that when skin rubs on skin such as the case with the hanging pannus it is prone to develop yeast infections. He told me short of removing the excess skin my only remedy was over the counter yeast infection medications, such as antifungal powder. 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.

 

As for affecting my life day to day, 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 affects my mobility and makes exercising extremely difficult. 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 affecting my life day to day, I hate the fact that in spite of my best efforts to prevent it, the skin flaps against me as I walk or run, making it uncomfortable and painful. This affects my mobility and makes exercising extremely difficult. I also need to apply the medicated powder to the area under my Pannus several times a day. I even have to apply the powder while at work, to try to keep the rash and odor in check. The hanging pannus, as well as the extra skin on my upper inner thighs keeps me from doing the strenuous work outs necessary to maintain my weight loss and overall health. The skin not only effects my range of motion it has actually gotten "caught" in the weight equipment at my YMCA. This happen more than once causing pinching and bruising and is extremely painful, not to mention very embarrassing.

.

Redhaired - Your'e awesome babe!!!  Using your recommendations,,,, Thanks!!

Hi Dawn.  Good letter and it makes perfect sense...except to the INS companies.  They want their criteria met, usually to the letter.  Your plan states

"Documentation of consult and treatment required."

So unless you have documented visits to the doctor, and also preferably the scripts you were given, the chances (at least down here in Texas with our plans) of getting approved are low.

Why is this?  Because they are in the business of making money and delivering "cost-effective care."  If you go to a dermatologist and get a script, they will likely get a $175 bill for the consult and a $65 bill for your medicines.  Multiply this times a year of skin problems and you are talking about a big expense for them.  Want to get their attention ? Hit them where they feel it. 

You and I know that until the excess skin is removed, the problems will persist.  This is just another flaming hoop you must jump through.  My office faces he same thing in dealing with them, but at least they provide the criteria for you that they want satisfied to approve your surgery. 

Best wishes and hope this helps !