I can't believe it!

[Guest guest]

I received the most wonderful letter today and want to share my

excitement with you all! As some of you may know, I've had an appeal

pending with Aetna concerning the removal of excess skin on my arms and

legs. They denied me two times and I filed for an external appeal (kind of

like binding arbitration....the final decision!) Well I got my answer

today!!

Dear Ms Barr:

Attached please find the expert review report for the external review

request for surgical removal of excessive skin and subcutaneous tissue

around the arms and thighs. Also included is a summary of the expert's

qualifications for your review. The reviewer concluded that the surgical

removal of excessive skin and subcutaneous tissue around the arms and thighs

is not cosmetic. If you have any questions, please contact Aetna US

Healthcare. We have also forward a copy to them.

Summary of Expert Qualifications

Review #S006

Received a BA from Yale University, New Haven, CT; MD from the University

of Alabama, AL. Completed internship and residency in general surgery and

residency in plastic and reconstructive surgery at Yale University School of

Medicine, New Haven, CT> Also completed postdoctoral fellowships in

molecular biology and in craniofacial surgery. Is board certified in

surgery and plastic surgery. Currently serves as Assistant Professor of

Surgery, Co-Director of the Craniofacial Center, and Director of Education,

Section of Plastic Surgery, Department of Surgery, at a well-known northeast

university affiliated school of medicine. Is active in research and is the

recipient of numerous professional honors and awards. Has done scientific

presentations and is published in peer-reviewed literature.

Sincerely,

Senior Case Review Manager

Summary of Clinical Case Information

The patient is a 45 year old woman with a large abdominal pannus following a

gastric bypass. She has lost between 200-300 pounds and has overhanging

excess skin and tissue from the arm and thighs with resultant intertriginous

rash as claimed by her physicians as well as patient. The appropriate ICD-9

codes for this includes:

278.1 localized adiposity

701.9 atrophoderma

695.89 intertrigo

The patient and physicians request brachioplasty CPT 15836 and excision of

thighs 15832 for excision of excessive skin-thighs.

Questions to be addressed by this review:

1. Is the surgical removal of excessive skin and subcutaneous tissue from

around the arms and legs cosmetic "

No.

The following definition of cosmetic and reconstructive surgery was put

forth by the American Medical Association in 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.

Weight loss following gastric bypass procedures often result in significant

folds of redundant tissue leading to areas of intertrigo which may result in

skin infections. Affected areas usually include abdominal wall and thighs

and arms as well as breast. Impaired ambulation and interference with

hygiene can also be seen.

The physician-patient has included documentation of the significant skin

laxity and redundant folds of skin by photographs of the patient. The

photographs demonstrate that the patient has intertrigo. The physician

office notes and patient letter document intertrigo.

This patients condition warrants medical corrective surgery to deal with

intertrigo and results following surgery for morbid obesity. Long term

health consequences may develop as a result of longstanding skin problems.

References:

1. , T.S. " Morbid Obesity. " Clinics in Plastic surgery,

11(3):517,1984

2. Palmer, B. " Skin Reduction Plastics Following Intestinal Shunt

Operations for Treatment of Obesity. " Scandinavian Journal of Plastic and

Reconstuctive Surgery, 9:47, 1975

3. Savage, R.C. " Abdominoplasty ;Following Gastrointestinal Bypass

Surgery. " Plastic and Reconstructive Surgery, 71(4):500, 1993.

4. Zook, B.G. " The Massive Weight Loss Patient. " Clinics in Plastic

Surgery, 2(3)457,1975

I have to tell you that I am saying special prayers of thanks to review

#S006 tonight! WOOHOO!!!!!