Reconstructive Surgery Resources - Teena Adler

7150 Greenville Ave

Suite 310

Dallas, TX 75231

214-368-3223 voice

214-368-3177 fax

Surgeries will be @ Presbyterian Hospital in Dallas

1. Takes pictures of every rash, sore, bump, mark, cut and infection you get as a post-op anywhere on your body - you never know where you might want to get skin removed, and mark the pic with the date and how many months post-op and pounds lost. If you go to a surgeon and he submits your info in without photos you will automatically get denied, as they want to see a visual of you and what your medical issues are. Most rashes are visible in photos so take your photos before you treat them with creams and powders. They worse your rash looks the better for photographic purposes.

2. Call your PCP every time you get a rash, sore, bump, mark or infection and ask them to prescribe a cream for you - mine always prescribed medications I had to get filled at Walgreen’s keep your receipts and labels in preparation for your letter (see #3). I sent my receipts in with my appeal info, as they wanted proof that I attempted to treat rashes. Most insurance companies want 3-6 months worth of documentation. That means going to a doctor and getting prescriptions for your issues. Please do not just go to the doctor and get a prescription thinking it will be listed in your chart. Get it filled, as you may need copies of it later on for the insurance company.

3. Tell your PCP NOW that when you approach your goal weight, you will be asking him/her for a letter of medical necessity for skin removal procedures, and ask your doctor to document every complaint you have about skin disorders, back pain, neck pain, shoulder pain, joint soreness, numbness, tingling and the like - it will help him/her write a more compelling letter a year down the road. I had letters from every doctor I saw: Dermatologist, Chiropractor, Physical Therapist, OB-GYN, PCP, WLS Surgeon, and Therapist (Shrink) as I wanted to make sure that they knew I had a serious enough problem physically as well as psychologically to see all of these doctors.

4. Take your own photos of hanging skin every 3-6 months, date them, list months out, pounds lost, and any problems the skin is causing. If you feel comfortable get a close family member to take them. My sister took my photos for me. I always took them while I was pulling on the skin so they could see just how far it stretched. I took them in various positions standing, stooping, bending, reaching, kneeling, and sitting down so they could see just how bothersome the skin was in my everyday living.

5. Learn the vocabulary and school the insurance person at the Plastic Surgeon's office in case they don't know - if you are not confident, ask them to let you review the request before it is submitted to insurance. Things to know: plastic surgery is never covered by insurance, reconstructive surgery often is. Elective procedures are never covered by insurance, so make sure yours is listed as medically necessary. Most insurance only consider reconstructive surgeries something caused by trauma or something that you were born with like a cleft palate or lip. Read your policy and get a clear definition of the terms reconstructive surgery and cosmetic for your policy because every insurance company and policy is different and unique. Every insurance company has their own definition so what your neighbor has even though it is the same insurance company it could be a different policy if you work for different companies. She could have exclusions on her plan where you could have none.

7. For you writers, when you journal, highlight the section where you talk about how your loose skin is starting to affect your quality of life, just in case you have to write an appeal letter later, you can look back on these notes to help you draft it. I had to include very personal details of how the rashes, pain, body odor associated with the excess skin was affecting my life. While insurance companies do not care about your emotions, they do have to take notice when medical conditions make it hard for you to carry out your everyday duties. I have severe back, neck, and shoulder pain and it is affecting everything I do. The rashes are so bad that they use cause me trouble walking (thigh lift cured that). I have problems lifting heavy items; I have trouble reaching for things. I can not sit or stand for long periods of time, numbness. You have to list things like that. Those are things that affect quality of life.

8. Never take no for an answer. Read your insurance policy and tear it apart and get a full understanding of what they need for documentation. You should have all of your documentation to show you have the need for surgery so use it. Do not count on your surgeon to do it all. They have other patients besides you and sometimes get sidetracked. Who knows your issues better than you do? Before they send your insurance your letter please read it as many surgeons to not include the necessary info as they hate dealing with insurance and they prefer you to pay cash. When they accept insurance they have to take less cash. Be your own advocate and read your letter before it is sent to be sure the things the insurance company care about are covered.

9. Insurance companies do not care that you have issues fitting into clothes and have to buy larger sizes or that your appearance is disfigured. They care about rashes, infections, back, neck, and shoulder pain, body odor, medications you have used to get rashes and infections treated, and the amount of time you attempted to treat the problems. Most insurance companies require 3-6 months of documentation. Save everything.

10. Document everything. Send it to them yourself and keep the originals as they always have a habit of loosing pertinent information. The main thing is to never give up. Do your research and be armed. Never let your emotions get to you during a hearing or appeal. They do not care about tears. Stick with the medical information. They are money hungry and try to save every cent even if it means you suffer because of their thriftiness.

P.S. I originally got tips 1-7 from Nittany and I tweaked them and added more text. Tips 8-10 are completely mine. I will warn you though, some insurance companies have exclusions on reconstructive/cosmetic surgeries period and nothing will work no matter what type of functional impairments you have. I had United Healthcare -EPO my first round and nothing worked. I switched to Independence Blue Cross July 2003 during open enrollment and hit the jackpot. They rock. I know how it works take my word for it. I got all of my surgeries approved because of the tips above and countless hours spent in the library reading medical journals.I also learned first hand from my four month process with United Healthcare -EPO earlier this year only to fight like hell and prove everything and still get denied. Good Luck and God Bless.

The information below is just my journal regarding reconstructive surgery and insurance approval and appeal process. Thank you and enjoy

01-30-03 – 6:30 am - Today is the day I have arrived. I have lost -114 pounds since LAP RNY surgery and now I am 191 and I am only overweight according to my BMI 29.9. I have 26 more pounds to lose til I reach my goal weight of 165. I also am excited and nervous today as I go see the Plastic Surgeon for my reconstructive surgery consult on my stomach and arms. Thank you all for the support. Wish me well .I LOVE YOU ALL.

6:58 am - Morning everyone. I am sitting here anxiously watching the clock and anticipating 8:30 am . I have my reconstrcutive consult with Dr. Morales at 9:00 am. I live 10 minutes from Baylor so I am sitting here getting my thoughts together. I am also looking over questions I received from someone online to ask him. I do not want to forget to ask important questions so I printed them out and will stick them in my purse.

I am so excited as I got up this morning and got on the scale (daily ritual for me). I was overyjoyed and shocked as I have lost another pound. Freaked about it, but ohh so happy. I now weigh 191 -114 pound loss since Lap RNY 6-6-02 BMI is now 29.9 which means I am no longer obese. I AM JUST OVERWEIGHT!!! That is the wildest thing for me.

I am so happy. I am emotional again this morning. You all do not know what WLS has done for me. Well maybe some of you do. I have my life back. I am able to live the kind of life I have always wanted. I am able to move now. I have energy. I am going to school to fulfil my dream of being a nurse.I am trying to get my all of self-esteem back (I have a little now) not as much as I should. I am a whole person again. I like to help others achieve their goals. I am a people person again. I longer live my life hidden in the shadows. I am me again.

All of you and you have been a great asset in my WLS journey. Rookies as myself have kept me motivated and on my toes and have been very supportive and you veterans have paved the way for me. I would be lost if you had not been open and honest with your stories. I hope that no matter where your life takes you, that you continue to keep us updated because through your stories we all grow. I will always be here to lend a helping hand to anyone who needs it. I may not have much, but I am always willing to share with others. Have a great day and an even better week. I LOVE YOU ALL.

10:43 am - I just got home from my consult with Dr. Morales. You all were right; IT WAS A PIECE OF CAKE. I got there and filled out updated paperwork and they made a copy of DL and insurance card. As I sat there and waited I reread my questions and was shaking uncontrollably. I felt like a crackhead waiting for my next score. When my name was called I literally jumped out of my skin and my seat. I was walked to the room and I was asked to slip on the famous paper gown and panties and was left by myself. Then I heard the knock on the door and I almost passed out, as I knew it was party time.

Dr. Morales walked in the door with his assistant Gracie and we began to talk and I asked all of my questions and he answered them very thoroughly and even added extra stuff I did not ask about. I then had to disrobe. I was so scared, but calmed down after 5 minutes. He was touching, pinching, pulling up, pulling down, and stretching all areas of my body. He also took out a tape measure. I felt like a McCall's Pattern. I thought he had plans to make a nice dress from the left over skin. Silence of the lamb's here I come.

He told me that I have done great with my workouts and all that I have now is skin. He told me that the circumfrential abdominoplasty would be best for me as I have skin on my lower abs as well as gluteus maximus, and hips. This means my scar will be all the way around. I am cool with that. I just want the skin gone. I then was escorted across the hall for my Nude debut. I was asked to get naked. Then the sweat began. I was so afraid for no reason. It was nothing. I was asked to turn various positions and flex this arm and that arm. I leaned over so that could see that my pannus was below my private area. Lovely thought, Me on the cover of Playboy..lol.

After the pictures were done I went and looked at before and after photos. After the photos I went to talk to Carol about money. Luckily, when I got laid off I got a nice little severance and pension packet and I now have 10,000. If insurance does not pay for extra stuff. I have the cash. I am so happy it is all over with. Now comes the waiting. Just like with WLS I will have to find something to keep myself preoccupied. Oh, yeah, School..lol. I LOVE YOU ALL HAVE A GREAT DAY.

02/14/03 - 12:41 pm - Hello everyone. I just wanted to write to let you people know that are pursuing reconstructive surgery that it is a good idea to obtain your information (letter requesting reconstructive surgery and documentation of redundant skin issues) from your doctors (dermatologist, chiropractors, WLS surgeon, Plastic Surgeon). I have been plagued with rashes, infections and back problems since the weight starting coming off.

I learned very early in my WLS journey that all of this needed to be documented during the course of your treatment. I have asked all of my doctors to write me letters stating my problems and have actually obtained a copy of the letters.

While the letters will be submitted by your plastic surgeon when it is time to request insurance approval, as we all know insurance companies have a habit of purposely losing our documents.

I have been very fortunate to find a great person at my insurance company who is a manager for the Medical review Department and has given me a local fax number for her. Since I have my documents I faxed them to her this morning. She stated that a decision would be made next week regarding my reconstructive surgery approvals.

I am not naive enough to believe that they will approve on the first request, but I am confident that my file is very thick and detailed as I have been keeping receipts and records. I just wanted to let you all know that the more records you keep and the more involved you are in your approval process the better things will go. It also helps that I do not have to bother my doctors because I have my own records. Have a great day. HAPPY VALENTINE'S DAY!!!!!

02/17/02 - 11:51 am - I knew I could count on all of you for love and support on my previous post today.It is a daily struggle, but I know I will overcome this demon.THANK YOU.

I have been battling it out with the insurance company regarding insurance approval for my reconstructive surgery procedures Abdominoplasty (15831)and Brachioplasty (15836). They have been lying like all insurance companies do regarding receiving information. They are the "ANTICHRIST".

Like I honestly believe my information is not in their hands and they are not receiving joy from terrorizing me with anticipation. It is almost as if they know I have to have surgery during my college spring break and they are trying to make me miss this on purpose.

As I was typing this message I called the insurance company and the office manager from my doctors office has called them this morning and now I have a case open. The waiting period for a decision to be made is 7-14 business days. EVERYONE PLEASE SEND ME MORE PRAYERS AND GOOD THOUGHTS. I may just meet my spring break deadline after all. I LOVE YOU ALL.

02/25/03 - I just thought I would write to let you all know what is going on with me. I am doing great with school and trying so hard to stay focused and motivated even though I am very angry and madder than hell about being denied abdominoplasty 15831 and brachioplasty 15836 on February 21, 2003 because they said they were cosmetic and my plan does not cover cosmetic procedures. DUHHHH!!! The procedures are reconstructive you idiots!!!

I have continued to work out 6 days a week for two hours. I have also continued to go to counseling for my anorexia/bulimia thoughts (NOT ACTIONS). I have also increased my food intake to two meals a day and one protein shake. I am very very proud of myself for that, as it is very hard for me to eat. The scene is totally hilarious. My eating reminds me of a mother trying to feed her two-year-old child and the child spits out the food and just really does not want it. lol. That is me. I play with my food and often make ugly faces to get it down. Reason being the thought of eating disgust me right now, but I know I have to eat to stay healthy and live. I a overcoming it day by day.

After hearing on the phone 02/21/03 that I was denied by United Healthcare-Select EPO for reconstructive surgery I was so shocked and off guard that I physically fainted right here in my apartment next to my computer desk. Got a nice little bump on my left cheek as proof of my madness.

After I literally picked myself up off of the floor I called them back madder than hell and asked why I was told 30 min earlier I was approved and the denied. I had called them back 30 min later to verify the approval, hence the shock and disappointment. No one knew anything as usual. IDIOT'S!! Why was I laid off and they have jobs??? hmmmmmmm.

I immediately hung up on her after getting no where and got all 11 pages of my appeal letter printed and 42 pages of my documentation together. I had medical records and letters from my WLS surgeon, reconstructive surgeon, PCP, Dermatologist, and Chiropractor stating every rash, infection, back, neck, and shoulder pain that I have had since WLS. I had receipts of every rash or infection medication I bought over the counter and through the pharmacy. How dare they tell me it was cosmetic in nature? I HAVE A REAL MEDICAL PROBLEM.

I was angry and went to Kinko's to make 4 sets of copies to start my appeal process. I know the people at Kinko's thought I was on crack because I was crying and flinging paper and making copies and just looking real mental.

I then went to the post office and mailed off all four packages. Three went to United Health Care Select - EPO (office in UT, CA, and TX) and the last to the Texas Insurance Commissioners office. I also faxed my pages to UHC offices in UT, CA, and TX) to try to speed things up.

I am not happy as my surgeries were scheduled for March 14, 2003, but I will be damned if I let them do this to me. They will pay. I never expected them to pay for my arms, but why not try. The worse they could say is no. They said no to both and that has led me to believe that they never read anything I sent them.

I know will have to wait 20-30 days before a decision can be made on my appeal. The funny thing is I sent the appeal before I even got the letter because of my inside connection (she is a supervisor for member services) she told me why I was denied and how they came to their conclusion. She also told me where to send the appeals package. She did not have to do that. She could have been a witch like everyone else at UHC and told me to wait for the letter. I wanted to let you all know that I have not given up and you should not either. EVER.

If they come back with another denial I will fight and fight ‘til I am a bloody mess, but they will pay. I have the cash from my severance package and savings, but why should I pay when it is my right to be treated for my medical conditions. Plus, I was going to pay off my car this year with the cash.

I wish everyone well on your insurance approvals, surgeries, and dealing with your cravings. You are all in my thoughts and prayers. I LOVE YOU ALL.

02/26/03 - 11:05 am - Hello everyone. I hope you are all having a great day. I am stuck in again, as it is icy here in Dallas, TX. I am stuck in the house with my protein bars, shakes, fitness magazines, and DISCOVERY HEALTH CHANNEL.YEA!!!!!

I am sick as a dog with some flu bug. School has been closed for two days now and needless to say studying is the last thing on my mind now. lol. I have managed to ski down to the apartment gym for my workouts.

I just wanted to let you all know how important it is to be involved with your insurance company when it comes to WLS and reconstructive surgery approvals.

As most of you know I was told 2-21-03 that I was approved and then 30 min later I called back to verify I was approved and was told I was denied. I filed for an appeal the same day.

Called today to see if the appeal info I had faxed and mailed had been received and was told today that my medical information just went into medical claims review yesterday.

I called back to verify 30 min later and was told the same thing that it is still in review and now it is specifically assigned to a nurse. She would not give me her name. DARN!! She also said the reason it has been assigned and is going back through the whole process is because of all of the misinformation I have been given, the fact that I have been given the run around, and a supervisor got involved and stepped in because of all the troubles.

Oh yeah I forgot to tell you of the two phone call messages I have gotten on my answering machine that say please call member services to give more info about your case. They leave no name or reference numbers and left only a phone number.

I did not know it was possible for a denial to be overturned without an appeal. I do not think it is. What they did was take back the denial and start over from scratch. So now it is as if my file just now came to their attention for the first time.

You all know I will call at 4:00 p.m. today because I do not believe anyone at the insurance company. THEY ARE ALL LIARS. lol. I have to verify what they say because I have caught them in a lie to many times already. Gotta stay proactive. lol

I am praying for insurance approvals, uneventful surgeries, and speedy recoveries for all. I LOVE YOU ALL.

06/18/03 - I now have a new plastic surgeon and a new insurance.I was unsuccessful in getting United Healthcare to approve any of my surgeries as they saw all of them cosmetic. My case is pending review as of 6/18/03 and my new policy states the following:

Title: Excision of Redundant Skin After Weight Loss

Policy #: 11.08.10a

Application of Medical Policy is determined by benefits and contracts. Benefits may vary based on product line, group or contract. Medical necessity determination applies only if the benefit exists and no contract exclusions are applicable. Individual member benefits must be verified.

In products where members are able to self-refer to providers for care and services, members are advised to use participating providers in order to receive the highest level of benefits.

This Medical Policy/Technology document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published.

Description with Scientific Evidence:

Loss of excessive weight may lead to redundant skin. Excision of redundant skin after weight loss in areas such as, but not limited to, the abdomen, lumbar region, arms, and/or thighs is medically necessary for intertrigo, monilial infestations, and/or panniculitis that have failed to resolve with conservative measures.

Policy:

Excision of redundant skin after weight loss is medically necessary for the treatment of the following conditions:

Recurrent and persistent suprapubic intertrigo that has failed prior treatment measures

Recurrent and persistent monilial infestations that have failed prior treatment measures

Recurrent and persistent panniculitis that has failed prior treatment measures

Excision of redundant skin after weight loss performed for all other indications is considered cosmetic. If cosmetic surgery is included in a group benefit contract as a covered service, the service is provided to members in such groups in accordance with the terms of the contract.

NOTE: To determine medical necessity, requests for excision of redundant skin after weight loss require review by the Company's Patient Care Management Department Cosmetic Review Team and documentation of failed prior treatment measures.

Policy Guidelines:

When the member's condition does not meet medical necessity criteria in the medical policy, the request for excision of redundant skin after weight loss is referred to the Cosmetic Review Team Medical Director. The Medical Director, utilizing internal Medical Policy Department Technology Assessment policy and procedure, will make a determination..

References:

Fuente del Campo A, Rojas Allegretti E, Fernandez Filho JA, Gordon CB. Regional dermolipectomy as treatment for sequelae of massive weight loss. World J Surg. 1998; 22:974-980.

Lockwood TE. Fascial anchoring technique in medial thigh lifts. Plast Reconstr Surg. 1988; 82:299-304.

Muhlbauer W. Radical abdominoplasty, including body shaping: representative cases. Aesthetic Plast Surg. 1989;13:105-110.

Consultants:

1 Company Medical Director with speciality in General Surgery

1 academic facility-based plastic surgeon

1 community-based plastic surgeon

Coding:

CPT CPT codes are not listed. It is the position of the American Medical Association (AMA) that CPT codes are proprietary to the AMA.

ICD Procedure 86.83

ICD Diagnosis 112.89, 112.9, 695.89, 729.39

HCPCS Level II N/A

Place of Service ASC, SPU, hospital outpatient, hospital inpatient

07/12/03 - 10:31 am - I am patiently waiting for insurance to approve my procedures. They have recived all documentation from me and my plastic surgeon except his pictures. They were mailed on Friday by regular mail. I mailed my copies by priority mail on Friday as well so hopefully I will know something by next week. I hope I am approved, but either way I need to hear a yes or a no so I can begin my appeal process. All of this waiting is truly messing with my mind. I just want to get rid of this pain and this skin. I have lost all of my weight, but am reminded on a daily basis of my past when I look in the mirror.

07/15/03 - 11:25 am - Hello my Handsome and Gorgeous AMOS Brothers and Sisters. I hope everyone is doing well. You guys are on my mind 24-7 and most of you I do not even know in person.lol.

I am literally sitting here at my apartment on pins and needles. Independence Blue Cross received my photos from my surgeon yesterday. This was the last piece of the puzzle that they were waiting for to make a decision on my abdominoplasty, brachioplasty, mastopexy, thighplasty, and hip lift.

I am sitting here dripping sweat and pacing the floors.I was so fidgety I decided to do funk aerobics (hip hop dance style-lots of dance moves) and then yoga. I am sure my neighbors are hating me right about now. Thank goodness I no longer weigh 305 or they would have filed a complaint on me.

My medical file of 250 pages and nude photos are currently with the director for review per the notes in the system and he will be calling me this afternoon.

I am trying not to get my hopes up because most insurance companies deny you the first time around, but per customer service and my contract this policy is different as it covers cosmetics if medically necessary per supporting documentation and treatment.

The smart part of me is preparing myself for heartache and disappointment, but the fighter in me has already prepared my appeal and am ready to kick butt and take names. There is no time to feel sorry for myself or play the poor me role. I have things to do..lol

I hate this feeling of waiting and not knowing my fate. I prefer to know everything that is in front of me and this waiting is absolutely the worst because in the meantime my scheduling is off.

I am a planner and I live my life by my day planner. I have no focus right now. lol. If I get a job soon I will have to be off work for a while for plastic surgery recovery. That does not look good to get a job and say oh yeah by the way I will be gone for a few weeks, but by all means please keep my job for me. Then school starts August 25th (fall semester) and who wants to be walking around like a lil old lady with nasty drains hanging everywhere.

I want to know now. Can you all tell I am a lil impatient? I will continue to pray that I can be patient and let things happen when God is ready for them to happen. I never said I had to like it though. I hope I will be able to post a positive update this evening regarding my plastic surgery saga. I LOVE YOU ALL. 07/16/03 – 1:07 pm - Hello My Handsome and Gorgeous AMOS Brothers and Sisters. I hope you all are having a great day because I am having the best day in my whole entire life thus far.

I am sure you will all understand when I report that I have been approved by Independence Blue Cross for Abdominoplasty, Brachioplasty, Mastopexy, Thigh-Lift, and Hip-Lift. I just got off the phone with the nurse that was working my case and I am approved.

Did you hear me I said APPROVED!!!! I am sure you all understand why this is thus far the best day of my life. I am really doing the HAPPY DANCE......I have been waiting for this moment for a very long time and now that it is here I do not believe it. I am in shock and am also in tears. I have worked very hard to use my tool to the best of my ability and now is the moment that begins completion of my journey for me.

Losing the weight was the main part of WLS as well as gaining my health. Regaining my self-respect and self-esteem were also part of my journey. I have come a long way in the last 13 months and now I will be able to show the world how good I feel on the inside on the outside. I will be able to move on in life and feel even more confident about my body (if there is such a thing). I will not have to spend money on creams and medications that will not work anymore. My skin will not arrive before I do when I walk or jog anymore. I am truly bouncing off the ceilings and I had to come and share my excitement with you today as you are my family and I LOVE YOU ALL. God Bless.

P.S. Now I am off to get this party started and get this body scheduled for a day of cutting, threading, and suction. Now watch my plastic surgeon be on vacation for two weeks now. lol. That would be my twisted fate. lol

UPDATE : I just got off the phone with my surgeon’s office and they will have to call me back to schedule, but they said that insurance told them they approved Abdominoplasty and Thigh lift only.

I am on the phone now with insurance appealing the other three surgeries (breast lift, arm lift, and hip lift). They said they were cosmetic. Yes they are, but my policy says that if there is a functional impairment they are covered therefore they need to pay for these.

You all know I already had my appeal letter ready right. I Just faxed it over. Let the fight begin. LET’S GET READY TO RUMBLE. I am still doing the Happy Dance over the TT and thigh lift though. Any surgeries approved are good in my book. I LOVE YOU ALL. Thank you for supporting and motivating me through your posts and emails.

07/17/03 12:03 pm - Hello my Handsome and Gorgeous AMOS Brothers and Sisters. I HAVE A DATE .. I HAVE A DATE.. I HAVE A DATE!

Today is a great day. I have the biggest goofiest smile on my face right now. YOU ALL KNOW THE ONE I AM TALKING ABOUT..

I will have an abdominoplasty and thigh lift on August 13, 2003 @7:20 am by Dr. Patrick Pownell at Presbyterian Hospital of Dallas.

Rhonda Williams is my angel and will be updating the board on my progress while I am in the hospital until I am able to update for myself.

Presbyterian Hospital of Dallas

8200 Walnut Hill Lane

Dallas, TX 75231-4402

(214) 345-6789