Abdominoplasty Appeal Letter
May 2, 2000
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Attention: Appeals Coordinator
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RE: Notice of Appeal
Dear Sirs:
Please accept this letter as "Notice of Appeal" In your letter dated April 26, 2000, you declined Consultation with Dr. Miller for Abdominoplasty Surgery. First let me say I was NOT requesting this abdominoplasty for "Cosmetic Reasons". I had Roux
en Y Gastric Bypass on December 8, 1999, and to date have lost over 100 pounds. My request was for "Surgical Consult for Abdominoplasty"
I require help for reconstruction of a extremely large Panniculus, (apron of fat and tissue) causing me severe back pain and spasms and
for medical complications with repeated infections under the Panniculus, which should and is considered a medical necessity. The
consult I requested was not for "Cosmetic Reconstruction" as you stated.
Definitions: Abdominoplasty is defined as a surgical procedure, which tightens a lax anterior abdominal wall and removes excess abdominal skin. It may be reconstructive or cosmetic. 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, but may also be done to approximate a normal appearance.
Abdominoplasty is considered reconstructive when performed to correct or relieve structural defects of the abdominal wall (ICD-9:
701.8/708.9) and/or chronic low back pain (ICD-9: 724.1) due to functional incompetence of the anterior abdominal wall. These conditions may be caused by:
1. Permanent overstretching of the anterior abdominal wall following one or more pregnancies; (ICD-9: 701.8.701.9).
2. Permanent overstretching (with or without diastasis recti (ICD-9: 928.84) of the anterior abdominal wall with a large or long abdominal
panniculus (ICD-9: 278.1) following weight loss in the treatment of morbid obesity and resulting in the uncontrollable intertrigo (crease
dermatitis, ICD-9: 692.9) and/or difficult ambulation (ICD-9 724.8).
3. Trauma or surgery to the anterior wall of the abdomen resulting in loss of muscle of fascial integrity or pain from scar contracture (ICD-9: 709.2).
4. Abdominal hernia following previous abdominal surgery (ICD-9: 553.201, 553.21). In my request for Surgical Consult my medical necessity relates exactly to Numbers 1-4 all four apply to my
condition. Panniculectomy is performed to relieve the massive apron of fat, (which I have attached pictures in the first appeal dated
April 12, 2000) is considered purely functional and therefore should be covered by my insurance policy. It is done to relieve uncontrolled
intertriginous dermatitis. I have constant rashes and infection causing difficulty in walking and occasionally actual skin necrosis.
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Abdominal dermolipectomy has been performed since the turn of the century. In the United States, H.A. Kelly called attention to this
procedure and its positive outcomes (weight reduction, personal comfort, convenience and comfort in dressing, better pose in standing
and walking, increased activity and greater ease in hygiene) in his 1910 publication. The anterolateral abdominal wall is largely
muscular and aponeurotic with overlying subcutaneous tissue and skin. It consists of two strap muscles in front, (the rectus abdominis and
phyraidalis), and
