PS Letters

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The journey is not measured by where we end up...
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For photos referred to in my PS Journal, please visit http://picturetrail.com/carolineam. The password to all the protected albums is ps . Some of the photos in the My Reconstructive Journey albums are of a very graphic nature (including photos of incisions, drains, excised skin, etc.). Please open them with care. I have decided to share these photos so that others going through a similar experience may know what to expect. Similarly, I share them so that it can be better understood what is meant by reconstructive plastic surgery as opposed to cosmetic plastic surgery.

I am still working on this page, so please feel free to check back soon!!! In the meantime, here are some of the letters sent to my insurance company from my treating physicians and plastic surgeon. I share these solely with the hope that they can be of help to others fighting a similar uphill battle with their insurance company to get needed reconstructive surgeries covered...

August 21, 2003

To Whom It May Concern:

Caroline Martin is a patient of mine who I referred for gastric bypass roux-en-y surgery which she had May 2, 2003. Her starting weight was 367 lbs with a BMI of 61.1. During the past 15.5 months, she has lost over 210 lbs and is currently a healthy weight for her height as well as a low body fat percentage.

Prior to her surgery, I treated Ms. Martin several times for rashes, cysts, boils, yeast infections and breakdown of her skin on or near her breasts, thighs, buttock, abdomen and arms related to the folds of fat and skin that were present due to her super morbid obesity.

Even with her weight loss of over 210 lbs, she continues to have an amazing amount of excess skin that presents ongoing medical problems including the above mentioned breakdown of skin, boils, cysts, etc. as well as neck and shoulder pain, lower back pain, severe itching, increased depression and anxiety, difficulty with movement, etc. During the past year, she has been on multiple courses of antibiotics as relates to these and other problems caused by the excess skin. The areas affected include her breasts, abdomen, upper and lower back, buttocks, medial and lateral thighs, and upper arms.

Ms. Martin was seen by plastic surgeon, XXXX specializing in post-bariatric reconstructive surgery in June 2003. It was his assessment, that reconstructive surgery including a lower body lift (abdominoplasty, buttock lift and lateral thigh lift), medial thigh lift, breast reconstruction (mastoplexy with implants), and grade 3 brachioplasty are all medically indicated for Ms. Martin. On August 16, 2004, Ms. Martin was seen by Monarch’s in-network plastic surgeon, XXXX, who confirmed the above recommendations and requested approval for the above reconstructive surgeries.

On examination of Ms. Martin and given her medical history that includes ongoing treatment for medical problems related to the excess skin, it is my assessment that the above requested plastic surgeries (abdominoplasty, buttock lift, lateral thigh lift, medial thigh lift, mastoplexy with implants, and brachioplasty) are medically necessary and not merely cosmetic in nature. Furthermore, the requested surgeries would be considered reconstructive as opposed to cosmetic given that years of dealing with super morbid obesity has left Ms. Martin with an amazing amount of excess skin that causes severe disfigurement and ongoing medical problems. Ms. Martin’s ability to walk, run, bend, have relations with her husband, prevent depression and anxiety, etc. are also affected by the excess skin.

The above reconstructive surgery can be expected to alleviate Ms. Martin’s medical issues related to the excess skin and resulting disfigurement. It is recommended that she be treated by a plastic surgeon specializing or at least extremely experienced in reconstructive surgery of post-bariatric patients, especially those who have lost 200+ lbs. To my knowledge, there is no such plastic surgeon within the Monarch network and it would be my recommendation that she be referred to post-bariatric specialist plastic surgeon, XXXX for the above mentioned surgeries.

If I can be of help in anyway in Ms. Martin’s seeking authorization of the above mentioned reconstructive surgeries with Dr. XXXX, please contact me at XXXX.

Sincerely,

L.G., Internist, M.D.

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October 22, 2004

Department of Managed Health Care

Re: Caroline Martin

To Whom It May Concern:

I am writing this letter for my patient, Caroline Martin, who has been denied coverage by Monarch Healthcare and Blue Shield of California for medial and lateral thigh lift, buttock lift, brachioplasty and mastopexy.

Mrs. Martin underwent successful gastric bypass surgery in May 2003 and lost approximately 220 pounds. We estimate that she now has approximately 30 pounds of excess skin on her buttocks, hips, arms, thighs, back, breasts and abdomen. Monarch Healthcare and Blue Shield of California granted authorization for an abdominoplasty, but have denied the additional procedures listed above.

The excess skin Mrs. Martin has on her buttocks, arms, thighs, back and breasts has caused multiple skin infections, which have been treated unsuccessfully with several courses of antibiotics. Mrs. Martin is also experiencing neck and back pain from the excessive skin on her arms, breasts, buttocks and thighs. These complications impede performing her daily activities. In addition, she and her husband are having difficulty performing sexual intercourse due to the excessive skin on her thighs and buttocks.

I wholeheartedly support Mrs. Martin’s decision to request an Independent Medical Review. In my opinion these procedures should certainly be considered medically necessary and as reconstructive and not as cosmetic.

Sincerely,

L.G., M.D.

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October 26, 2004

Department of Managed Health Care

Re: Caroline Martin

To Whom It May Concern:

I am writing this letter for my patient, Caroline Martin, who was denied coverage by Monarch Healthcare and Blue Shield of California for medial and lateral thigh lift, buttock lift, brachioplasty and mastopexy. Monarch Healthcare and Blue Shield of California granted authorization for an abdominoplasty, but have denied these other procedures saying that they are cosmetic and not medically necessary.

Mrs. Martin is a 35 year-old patient of mine who I performed gastric bypass surgery on May 2, 2003. She has done exceptionally well and has lost 220 pounds in the past 18 months. She is at a normal weight now, but has an extreme amount of redundant skin all over her body that causes her body structures to be rendered deformed and abnormal. The excess skin Mrs. Martin has on her buttocks, arms, thighs, back and breasts and abdomen causes her physical pain and medical problems. She has had ongoing, multiple skin infections which have been treated unsuccessfully with many courses of antibiotics. Mrs. Martin is also experiencing neck and back pain from the excessive skin on her arms, breasts, buttocks and thighs for which she has been prescribed narcotic pain medication by her primary care doctor.

It is my assessment that a lower body lift (abdominoplasty, buttock lift and lateral thigh lift), medial thigh lift, prophylactic mastectomy with reconstruction including implants (written as mastopexy), and brachioplasty are all medically necessary and should be considered as reconstructive, not as cosmetic. It is only with these surgeries that Mrs. Martin will be able to resume a normal body appearance and be free from pain, continued skin infections, intertrigo, and the functional limitations that the redundant skin causes.

Sincerely,

Andrew Hajduczek, M.D.

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October 26, 2004

Department of Managed Health Care

Re: Caroline Martin

To Whom It May Concern:

Mrs. Martin is a 35 year-old patient of mine who has been in therapy with me since January 2001. In May 2003, she had gastric bypass surgery and has since lost 220 pounds. She is at a normal weight now, but has an extreme amount of redundant skin left over that causes her physical and emotional pain. The excess skin Mrs. Martin has on her buttocks, arms, thighs, back and breasts has caused multiple skin infections which have been treated unsuccessfully with several courses of antibiotics. Mrs. Martin is also experiencing neck and back pain from the excessive skin on her arms, breasts, buttocks and thighs for which she has been prescribed narcotic pain medication. In addition, she and her husband are having difficulty performing sexual intercourse due to the excessive skin on her thighs and buttocks. These complications impede performing her daily activities and have been taking their toll on her emotional health. In my opinion these procedures should certainly be considered as reconstructive and medically necessary.

Similarly, during the time I have been working with Mrs. Martin, she has never complained about the appearance of her body. She has spoken much of needing to have reconstructive surgery to remove the skin, but only in the context of having this done for medical reasons and to gain a normal appearance. She has never spoken of needing to have the requested surgeries for cosmetic reasons, and indeed, she appears confident in her appearance.

Sincerely,

XXXX, M.F.C.C.

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November 1, 2004

Center for Health Dispute Resolution

ATT: XXXX

Fax: XXXX

RE: Caroline Martin, IMR Case #: XXXXXX

To Whom It May Concern:

This is my third appeal for authorization for medically necessary procedures for Ms. Caroline Martin. As you well remember, this is a 35-year-old female who had undergone gastric bypass. As of June 2004, she had lost over 190 pounds and had been left with a significant amount of skin and intertriginous fold redundancies. Underneath most of these intertriginous areas, there were rashes caused by the redundant skin, which led to chronic skin excoriation, scratching, and further ulcerations.

Since I saw the patient five months ago, the patient has lost even more weight which has led to even more skin redundancy and more intertriginous zones. She complains of daily rashes underneath each breast, bilateral inframammary fold, buttocks, medial and lateral thighs, abdomen and upper arms as well as boils in her medial thighs, buttocks, arms and back. This along with the volume and pulling/pinching of the excess skin creates a functional deformity and makes it very difficult for the patient to perform normal daily activities including running and walking. She has been seen by three other plastic surgeons, Dr. Thomas T. Nguyen, Dr. XXXX, and Dr. XXXX who all concur with the requested procedures being medically necessary and as reconstructive, not cosmetic. In addition, the patient’s primary doctor, Dr. XXXX, also believes that the patient’s procedures are medically necessary and reconstructive, not cosmetic.

In summation, it is my belief that the patient medically needs a circumferential body lift, which would include abdominoplasty, buttock lift and bilateral lateral thigh lift, and bilateral medial thigh lift. At a later stage, the patient will medically require a full incision brachioplasty and bilateral breast reconstructions.

I am formally requesting that you sincerely reconsider this patient’s unfortunate situation.

Thank you,

_________________________

XXXX, MD, FACS

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November 3, 2004

Department of Managed Health Care

XXXXXXXXXXXXX

Sacramento, CA 95826

Please refer immediately to XXXXXXXXXX

Re: Caroline Martin, IMR Case #XXXXXXX

To Whom It May Concern:

Mrs. Martin is a 35 year-old patient of the Coastal Center for Obesity who had gastric bypass surgery on May 2, 2003. She has lost 220 pounds in the past 18 months but has an extreme amount of redundant skin on her buttocks, arms, medial and lateral thighs, back, breasts and abdomen that causes ongoing skin rashes and infections, boils, cysts, pain, and functional impairments including inability to perform monthly self breast exams, keep her skin dry and free from infections, difficulty exercising, etc.

I examined Ms. Martin on November 2, 2004 for consideration of a lower body lift which would encompass abdominoplasty, buttock lift, and lateral thigh lifts. She presents an extreme amount of excess skin in these areas with the skin hanging down a foot or more from where it should be. There were multiple boils and cysts on her back, buttocks and thighs where the skin folds over itself, and she had a large rash between her buttocks caused by and hidden from the excess skin in this area. It is my assessment that reconstructive surgery is medically necessary and would afford Ms. Martin the ability to resume normal functioning free from the medical complications she has been facing due to the redundant skin. She would benefit from a lower body lift that would remove the redundant skin and would also need for medical reasons, reconstructive surgery to remove the redundant skin from her medial thighs, breasts, back and upper arms.

Sincerely,

D.O., M.D.

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November 2, 2004

Monarch Healthcare

Re: Caroline Martin (Participant ID: XXXXXX)

To Whom It May Concern:

Mrs. Caroline Martin is a 35-year old female with a history of severe obesity who underwent gastric bypass procedure approximately 18 months ago. I am writing this letter to request preauthorization for the above mentioned patient for treatment of excess skin status post extreme weight loss (370 lbs to 145 lbs). She now has an extremely severe case of symptomatic excess/loose skin throughout her body, including breasts, arms, abdomen, buttocks and thighs. In all mentioned areas, she has a history of severe skin problems, including intertrigo, yeast infections, boils, cysts, rashes and sores. Her breasts are severely ptotic with the sternum-nipple measurement of 34 cm bilaterally. The skin conditions in all of these have been unsuccessfully treated by antibiotics and antifungal creams and pose a recurrent health risk if the excess skin is not removed. Also, because the breasts are so severely atrophic, she will require augmentation to form a breast mound.

In addition to the skin diseases mentioned, functional problems also exist with regards to the excess skin about the abdomen, buttocks and thighs. This skin is so severely redundant that proper hygiene is prohibited. The patient states that she has difficulty using the toilet without her skin entering the water in the basin. She is also prohibited from having sexual relations with her husband because of the resulting sores due to the excess skin in her pubic area. In order to alleviate the skin problems and functional problems, it is medically necessary to remove the excess skin from all the mentioned areas. The required procedures are as follows:

Mastopexy: 19316

Augmentation Mammoplasty: 19325

Brachioplasty: 15836

Panniculectomy with layer closure of wound: 15831 & 12035

Excision of Excess Skin, Outer Thigh: 15832

Excision of Excess Skin, Inner Thigh: 15832-50

Excision of Excess Skin, Buttocks: 15835

The procedures will be performed in two to three stages as Outpatient Procedures at the Fountain Valley Regional Hospital in Fountain Valley, CA (TIN# XX-XXXXXXXX).

In my professional opinion, it is necessary for the overall health and psychological well-being of the patient to proceed with the treatment outlined. If you have any questions, please do not hesitate to contact me at (xxx) xxx-xxxx.

Sincerely,

T.N., Board Certified Plastic Surgeon, M.D.

TIN# xx-xxxxxxxxxx

Pictures enclosed

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Visits to this site, http://AButterflyEmerges.com as of June 4, 2005:

The journey is not measured by where we end up... but by how far we've traveled.

The journey is not measured by where we end up...
but by how far we've traveled.