Because so many have asked...
Here is a copy of the third letter that I sent to my insuranvce before they covered my procedures. I must credit Diana Cox from the DS board, as most of the content came from a letter she put together.
April
July 10, 2009 To Whom it May Concern: Please accept this letter as a “Third Notice of Appeal." In your letter dated February 20, 2009, you again denied my proposed Abdominoplasty, Lower Body Lift, and Bilateral Thighplasty, by Dr. XXX (Reference number XXXXX). Once again, let me say I am NOT requesting the Abdominoplasty, Lower Body Lift, and Bilateral Thighplasty for "Cosmetic Reasons." I had Roux en Y Gastric Bypass on December 10, 2007, and to date have lost 157 pounds **** pounds since surgery). The surgeries that Dr. XXX have and will be performing are considered reconstructive, not cosmetic, and are therefore medically necessary. On June 10, 2009 I underwent removal of excess skin from the abdomen, back, buttocks, and outer thighs with payment made out of pocket at a cost of $XXX for surgeon’s fees and $XXX for the operating room and anesthesia fees. This date is 18 months post bariatric surgery, which was performed on December 10, 2007. Additionally, I have been at a stable weight since December 16, 2008. Dr. XXX, my bariatric surgeon, has been documenting my weight on a monthly basis. I saw him on December 16, 2008 with a weight of 155, on January 19, 2009 with a weight of 156, on February 11, 2009 with a weight of 155, and March 18, 2009 with a weight of 154. I have included a letter from my bariatric surgeon in support of these facts. During the reconstructive surgery on June 10, 2009, Dr. XXX removed a 17 lb. pannus. The date for the Thighplasty has yet to be determined. I have included the documentation and information needed to make an informed decision about the approval of my additional reconstructive surgery. Again, I am requesting that a surgeon certified by the American Board of Plastic Surgery review my file as well and that I be provided with the name of said surgeon. Dr. XXX originally submitted all documentation, including photographs in order to verify that the need for reconstructive surgery in my case meets the terms of the California Health and Safety Code 1367.63, which mandates that Anthem Blue Cross Life and Health Insurance Company (as a provider of a health care service plan contract issued or delivered in California on or after July 1, 1999) cover reconstructive surgery that is necessary to achieve the purposes specified in paragraphs (1) or (2) (note: in the alternative, not conjunctive) subdivision (c) of that section: 1367.63. (a) Every health care service plan contract, except a specialized health care service plan contract, that is issued, amended, renewed, or delivered in this state on or after July 1, 1999 Every health care service plan contract, except a specialized health care service plan contract, that is issued, amended, renewed, or delivered in this state on or after July 1, 1999, shall cover reconstructive surgery, as defined in subdivision (c), that is necessary to achieve the purposes specified in paragraphs (1) or (2) of subdivision (c). Nothing in this section shall be construed to require a plan to provide coverage for cosmetic surgery, as defined by subdivision (d). (b) No individual, other than a licensed physician, competent to evaluate the specific clinical issues involved in the care requested, may deny initial requests for authorization of coverage for treatment pursuant to this section. For a treatment authorization request submitted by a podiatrist or an oral and maxillofacial surgeon, the request may be reviewed by a similarly licensed individual, competent to evaluate the specific clinical issues involved in the care requested. (c) “Reconstructive surgery" means surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) To improve function. (2)To create a normal appearance, to the extent possible. (d) “Cosmetic surgery" means surgery that is performed to alter or reshape normal structures of the body to improve appearance. (e) In interpreting the definition of reconstructive surgery, a health care service plan may utilize prior authorization and utilization review that may include, but need not be limited to, any of the following: (1) Denial of the proposed surgery if there is another more appropriate surgical procedure that will be approved for the enrollee. (2) Denial of the proposed surgery or surgeries if the procedure or procedures, in accordance with the standard of care as practiced by physicians specializing in reconstructive surgery, offer only minimal improvement in the appearance of the enrollee. (3) Denial of payment for procedures performed without prior authorization (4) For services provided under the Medi-Cal program (Chapter 7 (commencing with Section 14000) of Part 3 of Division 9 of the Welfare and Institutions Code), denial of the proposed surgery if the procedure offers only minimal improvement in the appearance of the enrollee, as may be defined in any regulations that may be promulgated by the State Department of Health Services. Abnormal structures of the body (see below); Caused by…disease (specifically, morbid obesity, ICD-9 Code 278.01), for which I was successfully treated by bariatric surgery on December 10, 2007, by Dr. XXX, in which the procedure itself was medically necessary and covered by Anthem Blue Cross Life and Health Insurance; for which condition of reconstructive surgical procedures which were requested for pre-certification will create a normal appearance, to the extent possible, and the procedures, in accordance with the standard of care as practiced by physicians specializing in reconstructive surgery such as Dr. XXX (referring surgeon), offer substantially more than a minimal improvement in my appearance. The abnormal structures of my body caused by morbid obesity include, but are not limited to: a. A significant panniculus that hangs past the mons area and onto the upper thighs after massive weight loss. b. Significant amount of loose flesh hanging from buttocks and hips after massive weight loss c. Significant amount of loose flesh hanging from thighs, in particular the inner thighs, but also the back, front, and outer thighs, after massive weight loss These are clearly abnormal structures of my body, caused by the disease of morbid obesity and remaining after the successful treatment of that disease by bariatric surgery. The reconstructive procedures submitted for pre-certification include: a. 15830- Excise excess skin and subcutaneous tissue from abdomen (Abdominoplasty) b. 15832- Excise excess skin and subcutaneous tissue from thighs (Bilateral Thighplasty) c. 15833, 15834, 15835- Excise excess skin and subcutaneous tissue from legs, hips, and buttocks (Lower Body Lift) These are clearly appropriate reconstructive surgeries for treatment of abnormal body structures, are not merely cosmetic procedures for reshaping normal structure of the body in order to improve appearance, and these procedures offer substantially more than a minimal improvement in my appearance. It is my understanding that if the patient’s condition meets the requirements of the California statute mentioned above, imposing an additional medical necessity requirement is improper. Dr. XXX is the plastic surgeon who will be performing the procedures. I am requesting that you (Anthem Blue Cross Life and Health Insurance Company) make a "good faith" review of this request. I ask that you review all medical documentation and photographs submitted previously by Dr. XXX before a determination is made. I ask that you approve this surgery based on the terms and conditions on my policy, my doctor's recommendation, and California statute, and medical necessity. These surgeries are necessary to restore physiologic function. I look forward to a response within 30 days of your receipt of this letter. Sincerely, April XXX Home: XXX Cell: XXX Work: XXX
ASPS Position Paper
Treatment of Skin Redundancy Following Massive Weight Loss: 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 percent 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:
April
July 10, 2009 To Whom it May Concern: Please accept this letter as a “Third Notice of Appeal." In your letter dated February 20, 2009, you again denied my proposed Abdominoplasty, Lower Body Lift, and Bilateral Thighplasty, by Dr. XXX (Reference number XXXXX). Once again, let me say I am NOT requesting the Abdominoplasty, Lower Body Lift, and Bilateral Thighplasty for "Cosmetic Reasons." I had Roux en Y Gastric Bypass on December 10, 2007, and to date have lost 157 pounds **** pounds since surgery). The surgeries that Dr. XXX have and will be performing are considered reconstructive, not cosmetic, and are therefore medically necessary. On June 10, 2009 I underwent removal of excess skin from the abdomen, back, buttocks, and outer thighs with payment made out of pocket at a cost of $XXX for surgeon’s fees and $XXX for the operating room and anesthesia fees. This date is 18 months post bariatric surgery, which was performed on December 10, 2007. Additionally, I have been at a stable weight since December 16, 2008. Dr. XXX, my bariatric surgeon, has been documenting my weight on a monthly basis. I saw him on December 16, 2008 with a weight of 155, on January 19, 2009 with a weight of 156, on February 11, 2009 with a weight of 155, and March 18, 2009 with a weight of 154. I have included a letter from my bariatric surgeon in support of these facts. During the reconstructive surgery on June 10, 2009, Dr. XXX removed a 17 lb. pannus. The date for the Thighplasty has yet to be determined. I have included the documentation and information needed to make an informed decision about the approval of my additional reconstructive surgery. Again, I am requesting that a surgeon certified by the American Board of Plastic Surgery review my file as well and that I be provided with the name of said surgeon. Dr. XXX originally submitted all documentation, including photographs in order to verify that the need for reconstructive surgery in my case meets the terms of the California Health and Safety Code 1367.63, which mandates that Anthem Blue Cross Life and Health Insurance Company (as a provider of a health care service plan contract issued or delivered in California on or after July 1, 1999) cover reconstructive surgery that is necessary to achieve the purposes specified in paragraphs (1) or (2) (note: in the alternative, not conjunctive) subdivision (c) of that section: 1367.63. (a) Every health care service plan contract, except a specialized health care service plan contract, that is issued, amended, renewed, or delivered in this state on or after July 1, 1999 Every health care service plan contract, except a specialized health care service plan contract, that is issued, amended, renewed, or delivered in this state on or after July 1, 1999, shall cover reconstructive surgery, as defined in subdivision (c), that is necessary to achieve the purposes specified in paragraphs (1) or (2) of subdivision (c). Nothing in this section shall be construed to require a plan to provide coverage for cosmetic surgery, as defined by subdivision (d). (b) No individual, other than a licensed physician, competent to evaluate the specific clinical issues involved in the care requested, may deny initial requests for authorization of coverage for treatment pursuant to this section. For a treatment authorization request submitted by a podiatrist or an oral and maxillofacial surgeon, the request may be reviewed by a similarly licensed individual, competent to evaluate the specific clinical issues involved in the care requested. (c) “Reconstructive surgery" means surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) To improve function. (2)To create a normal appearance, to the extent possible. (d) “Cosmetic surgery" means surgery that is performed to alter or reshape normal structures of the body to improve appearance. (e) In interpreting the definition of reconstructive surgery, a health care service plan may utilize prior authorization and utilization review that may include, but need not be limited to, any of the following: (1) Denial of the proposed surgery if there is another more appropriate surgical procedure that will be approved for the enrollee. (2) Denial of the proposed surgery or surgeries if the procedure or procedures, in accordance with the standard of care as practiced by physicians specializing in reconstructive surgery, offer only minimal improvement in the appearance of the enrollee. (3) Denial of payment for procedures performed without prior authorization (4) For services provided under the Medi-Cal program (Chapter 7 (commencing with Section 14000) of Part 3 of Division 9 of the Welfare and Institutions Code), denial of the proposed surgery if the procedure offers only minimal improvement in the appearance of the enrollee, as may be defined in any regulations that may be promulgated by the State Department of Health Services. Abnormal structures of the body (see below); Caused by…disease (specifically, morbid obesity, ICD-9 Code 278.01), for which I was successfully treated by bariatric surgery on December 10, 2007, by Dr. XXX, in which the procedure itself was medically necessary and covered by Anthem Blue Cross Life and Health Insurance; for which condition of reconstructive surgical procedures which were requested for pre-certification will create a normal appearance, to the extent possible, and the procedures, in accordance with the standard of care as practiced by physicians specializing in reconstructive surgery such as Dr. XXX (referring surgeon), offer substantially more than a minimal improvement in my appearance. The abnormal structures of my body caused by morbid obesity include, but are not limited to: a. A significant panniculus that hangs past the mons area and onto the upper thighs after massive weight loss. b. Significant amount of loose flesh hanging from buttocks and hips after massive weight loss c. Significant amount of loose flesh hanging from thighs, in particular the inner thighs, but also the back, front, and outer thighs, after massive weight loss These are clearly abnormal structures of my body, caused by the disease of morbid obesity and remaining after the successful treatment of that disease by bariatric surgery. The reconstructive procedures submitted for pre-certification include: a. 15830- Excise excess skin and subcutaneous tissue from abdomen (Abdominoplasty) b. 15832- Excise excess skin and subcutaneous tissue from thighs (Bilateral Thighplasty) c. 15833, 15834, 15835- Excise excess skin and subcutaneous tissue from legs, hips, and buttocks (Lower Body Lift) These are clearly appropriate reconstructive surgeries for treatment of abnormal body structures, are not merely cosmetic procedures for reshaping normal structure of the body in order to improve appearance, and these procedures offer substantially more than a minimal improvement in my appearance. It is my understanding that if the patient’s condition meets the requirements of the California statute mentioned above, imposing an additional medical necessity requirement is improper. Dr. XXX is the plastic surgeon who will be performing the procedures. I am requesting that you (Anthem Blue Cross Life and Health Insurance Company) make a "good faith" review of this request. I ask that you review all medical documentation and photographs submitted previously by Dr. XXX before a determination is made. I ask that you approve this surgery based on the terms and conditions on my policy, my doctor's recommendation, and California statute, and medical necessity. These surgeries are necessary to restore physiologic function. I look forward to a response within 30 days of your receipt of this letter. Sincerely, April XXX Home: XXX Cell: XXX Work: XXX
ASPS Position Paper
Treatment of Skin Redundancy Following Massive Weight Loss: 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 percent 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.
160 lbs lost to date!
LBL: 6/10/09
BL/BA/Brachio: 7/14/09
MTL: 6/17/10
Thank you for posting this. Can you clarify what they eventually covered? I am a little confused, from your post it almost sounds like you had your plastic surgeries first and then had insurance cover it after the fact?
~Cindy
Watch my first appearance on The Doctors TV Show (aired Dec 2008)
Plastics done by Siamak Agha, MD (lower body lift/spiral thigh lift) in Dec 2009, breast
Cynthia's Lower Body Lift procedure by Dr. Siamak Agha this includes footage from my first and second appearance on The Doctors as well as footage of my actual surgery
Watch my first appearance on The Doctors TV Show (aired Dec 2008)
Plastics done by Siamak Agha, MD (lower body lift/spiral thigh lift) in Dec 2009, breast
Cynthia's Lower Body Lift procedure by Dr. Siamak Agha this includes footage from my first and second appearance on The Doctors as well as footage of my actual surgery
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