A Gardiner man’s bid to have surgery to remove excess skin after losing 500 pounds was dealt a blow last week when his insurance company declined to pay for the procedure.
Thomas Towle’s health insurance provider, Aetna, said it was declining coverage for the procedure to remove the skin from Towle’s chest, stomach and thighs because it is considered elective cosmetic surgery rather than medically necessary.
“It’s not cosmetic,” Towle said. “I’m not looking for the effects people are looking for in body contouring. I’m looking to get rid of skin rashes and body discomforts and to live a better, healthier life.”
Towle, who plans to appeal the denial, has requested a peer-to-peer review during which his surgeon, Alan Harmatz of Central Maine Plastic Surgery, will speak directly to a physician affiliated with Aetna. Towle’s procedure, which is expected to total about $30,000, could still be approved, said Aetna spokeswoman Cynthia Michener.
“If he meets the criteria, it will be resolved at the peer-to-peer,” she said. “We can get the information directly from his treating physician. It sounds like we’re trying to get this resolved for the member.”
Towle, 35, weighed in excess of 800 pounds before he reached his 20s. His doctor at one point said Towle would live less than a year without losing weight, which often reduced him to walking around his house on his knees to spare the tremendous strain on his feet, ankle and knee joints.
The weight forced Towle into deeper isolation until he finally dropped out of high school. Going to school was too difficult and seeing the other students was too embarrassing, he said.
After getting a job at McDonald’s, Towle brought his weight down gradually, losing about 200 pounds through improved diet and additional exercise. He tried to read his body better, to stop eating when he felt full. Having a job helped change his outlook, even if he had to come home from that job and collapse until it was time to go back. He still weighed close to 600 pounds.
SKIN DISCOMFORT
In June of 2011, Towle underwent Roux-en-y gastric bypass surgery, in which a surgeon used a portion of Towle’s stomach to create a second smaller stomach. The smaller stomach not only holds less food, creating a sensation of being full after eating about a cup’s worth, but it also passes nutrients more quickly, meaning fewer calories are absorbed.
Aetna covered the procedure.
Nationally, the number of bariatric surgeries performed each year has grown from an estimated 158,000 in 2011, the year of Towle’s surgery, to 179,000 in 2013, according to the American Society of Metabolic and Bariatric Surgery.
Towle, who had to lose more than 50 pounds to prepare for the surgery, tipped the scale at just over 500 pounds at the time of the procedure. He has since dropped more than 200 pounds and now weighs about 270. Towle said about 20 pounds of that weight is excess skin that drapes off his body. He has to wear pressure garments on his torso to try and contain the extra skin. He gets rashes, sores and irritation in the folds of skin that require a daily application of prescription creams and powders. The irritations persist, particularly around his chest and thighs.
Towle is scheduled to have reconstructive surgery on April 30 that will remove the excess skin from his chest, around his abdomen and from his thighs.
Aetna in 2012 approved a panniculectomy, a procedure to remove the apron of excess skin that hung below Towle’s belly button. He was confident Aetna would at least pay for the procedure to remove skin from his thighs and chest, where the sores are most troublesome.
“I was very surprised,” Towle said of receiving the rejection notice.
Towle was less confident that Aetna would pay to remove the skin from around his abdomen, which is called a circumferential body lift, so Towle started a GoFundMe account to raise the $12,000 needed for that part of the procedure. He has received about $6,000 so far, but is discouraged he might have to come up with another $24,000 to pay for all three procedures out of pocket.
“I’m not looking to become the next supermodel,” Towle said. “I just want to live a healthy, normal, active lifestyle.”
APPEAL POSSIBLE
Towle said his primary care physician is recommending he visit a dermatologist to better control the rashes and sores and a physical therapist to alleviate back pain exacerbated by the weight of the extra skin. Aetna will likely pay for that additional treatment, not to mention the prescription cream and powders, which will soon add up to thousands of dollars.
“It’s going to be to their benefit long term, mentally and physically,” Towle said. “This is not only a physical drain, this is starting to be very much a mental drain.”
Federal privacy laws prevent Michener, the Aetna spokeswoman, from speaking about Towle’s case specifically, but she said Aetna weighs claims on clinical standards that are based on studies and national standards. She said surgery to remove excess skin is often covered.
“It is considered medically necessary, and therefore covered, in a number of circumstances,” she said.
Michener said the company bases its decision on information that is available at the time. With additional information it could reverse its decision. She said there are sometimes technical glitches with filing deadlines, even a wrong code entered mistakenly, that can cause a procedure to be rejected.
“It could be a simple glitch like that,” she said. “People should always take advantage of their opportunity to appeal a decision.”
Emily Brostek, executive director of Maine Consumers for Affordable Healthcare, said it is not uncommon for insurance companies to initially decline services that are medically necessary. Her agency helps people navigate the waters of an appeal by offering legal advice and guidance.
“Unfortunately, not everybody takes that step of filing for an appeal,” Brostek said. “People think they won’t be successful.”
But the appeal process often gives companies additional information they need to justify the claim. In Towle’s case, Brostek said, Aetna may simply need more information to prove the skin removal procedure is medically necessary.
Brostek said about half of all appeals are successful. Those who work with Brostek’s agency during their appeal are successful about 70 percent of the time.
Brostek is unfamiliar with Towle’s case, but said she is not surprised the skin removal procedure was denied.
“If there’s a legal argument to be made that it’s cosmetic, I’m not surprise they denied it,” Brostek said.
Towle agreed that Aetna is following procedure and remains hopeful the company will eventually reverse course and pay for the surgery because his doctors have lots of evidence of the medical problems caused by the extra skin.
“It’s standard yes, but it shouldn’t have been because the evidence was there,” Towle said. “This is not plastic surgery.”
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