Prev: Uterine leiomyosarcoma prognosis unduly optimistic?
Next: Aloe vera juice?
From: jay on 14 Sep 2005 00:32
A dermatologist removed (shaved off) two moles that were confirmed by the
lab to be dysplastic nevi (benign but pre-cancerous), and he wants me to
come back in 3 weeks to have more moles that he suspects are atypical.
Since he tells me he can only remove a couple per visit, I fear he's going
to keep making me come back again and again (every 3 weeks). I asked if I
would be charged for just the removals rather than be charged repeatedly for
the evaluation fee, but he tells me that normally they charge an evaluation
fee for each visit plus the fee for the removals.

The moles are roughly the size of a pencil eraser or smaller. Is there any
medical reason why only two moles can be removed per visit, or is he just
trying to squeeze more "evaluation fees" out of me? KEY QUESTION: What is
the max number of moles that normally can be removed per visit?

By the way, this new dermatologist seems more aggressive than the previous
one, because the moles he removed were moles that the previous one passed
over and did not remove (and they have not changed recently). If the lab
really confirms they are dysplastic nevi, then being aggressive (and
removing them rather than doing nothing) isn't a bad thing, right?

Thanks,

J.



From: SJ Doc on 14 Sep 2005 01:48
On Wed, 14 Sep 2005 04:32:02 GMT, "jay" wrote:

>A dermatologist removed (shaved off) two moles that were confirmed by the
>lab to be dysplastic nevi (benign but pre-cancerous), and he wants me to
>come back in 3 weeks to have more moles that he suspects are atypical.
>Since he tells me he can only remove a couple per visit, I fear he's going
>to keep making me come back again and again (every 3 weeks). I asked if I
>would be charged for just the removals rather than be charged repeatedly for
>the evaluation fee, but he tells me that normally they charge an evaluation
>fee for each visit plus the fee for the removals.
>
>The moles are roughly the size of a pencil eraser or smaller. Is there any
>medical reason why only two moles can be removed per visit, or is he just
>trying to squeeze more "evaluation fees" out of me? KEY QUESTION: What is
>the max number of moles that normally can be removed per visit?
>
>By the way, this new dermatologist seems more aggressive than the previous
>one, because the moles he removed were moles that the previous one passed
>over and did not remove (and they have not changed recently). If the lab
>really confirms they are dysplastic nevi, then being aggressive (and
>removing them rather than doing nothing) isn't a bad thing, right?

To be perfectly bastardly about it, the number of lesions a skin
flicker will remove in any one visit depends *precisely* on the
number at which your insurance carrier will refuse to pay for
any more moles to be extirpated in a single session. The pleasure
of waving sharp objects around is nothing compared with the joy
of getting paid for it.

And you're saying that he's doing *shave* biopsy excisions?
In other words, no full-thickness excisions? Whee! If they're
as small as you say (i.e., no more than about four or five mil-
limeters (4 to 5 mm) in diameter, he could fulgurate them
(burn them with electrocautery), freeze them (liquid nitrogen
works fine for me), or even chemically destroy them (I like
trichloroacetic acid, but I'm a fan of that old Steve McQueen
movie *The Blob*; and can you imagine anybody keeping
what had to have been a quart bottle of high-molarity TCA
on top of an easily-jiggled instrument cabinet? I've never
bought it in bottles bigger than about 30 cc total capacity,
and you apply it in fiddlin' little droplets with a toothpick).

I think removal of the lesions is justified. If, however, he's
not going to do more than shave excision procedures, and
he's got repeat histopathology samples to prove that the
lesions are overwhelmingly non-malignant (meaning full-
thickness excisions, parsimonious or wide, aren't needful),
then he might as well go at 'em with purely destructive
extirpation. It won't derange the lymphatic architecture
(meaning that regional lymph node mapping - via lympho-
scintigraphy and/or intraoperative dye mapping - isn't
foreclosed). And destructive techniques are quicker and
easier than getting a 15 blade bloody.

You might want to get somebody else's opinion on your
treatment at this stage. Consider consulting a surgeon
oncologist (preferably a member of the Society of
Surgical Oncology if you're in these United States).
The SSO includes a kind of informal "Melanoma Mafia"
with special interest in pigmented tumors. One top
"capo" in the Melanoma Mafia is Douglas Reintgen,
who was working out of Moffitt Cancer Center in
southern Florida when last I spoke with him. There's
a bunch of other "soldiers" and "underbosses" around
the country, but I don't know where you live.

If you want to stick with the skin-flickers, maybe you
should find a specialty clinic, like the Pigmented Lesion /
Melanoma Clinic at the University of Pennsylvania
(http://www.pennhealth.com/dermatology/hup/lesion.html),
which is the regional center to which I've referred some of
the most damnable cases over the past couple of decades.
All things considered, I trust the surgeons at 34th & Spruce
to keep the superficiologists honest.

------------------------
Health care is too expensive, so the Clinton administration
is putting a high-powered corporate lawyer in charge of making
it cheaper. (This is what I always do when I want to spend less
money - hire a lawyer from Yale.) If you think health care is
expensive now, wait until you see what it costs when it's free.

-- P.J. O'Rourke, "The Liberty Manifesto" (1993)
(http://www.cato.org/speeches/sp-orourke.html)
From: jay on 14 Sep 2005 03:28
Thanks for the reply. Yes, the excision was done simply by slicing off the
moles and no stitches were required afterward, just a bandaid. By the way,
I'm located in northeastern NJ.

Thanks again,

J.


From: Howard McCollister on 14 Sep 2005 07:28

"jay" <jaynews(a)verizon.net> wrote in message
news:6JNVe.10584$c27.7417(a)trndny01...
>A dermatologist removed (shaved off) two moles that were confirmed by the
>lab to be dysplastic nevi (benign but pre-cancerous), and he wants me to
>come back in 3 weeks to have more moles that he suspects are atypical.
>Since he tells me he can only remove a couple per visit, I fear he's going
>to keep making me come back again and again (every 3 weeks). I asked if I
>would be charged for just the removals rather than be charged repeatedly
>for the evaluation fee, but he tells me that normally they charge an
>evaluation fee for each visit plus the fee for the removals.
>
> The moles are roughly the size of a pencil eraser or smaller. Is there
> any medical reason why only two moles can be removed per visit, or is he
> just trying to squeeze more "evaluation fees" out of me? KEY QUESTION:
> What is the max number of moles that normally can be removed per visit?
>
> By the way, this new dermatologist seems more aggressive than the previous
> one, because the moles he removed were moles that the previous one passed
> over and did not remove (and they have not changed recently). If the lab
> really confirms they are dysplastic nevi, then being aggressive (and
> removing them rather than doing nothing) isn't a bad thing, right?
>


It's hard to know - every office runs differently. Most likely it's all he
has time for relative to the amount the insurance company pays compared
other patients he might be seeing. Or possibly he just doesn't like doing
mole biopsies. There's no medical reason - you could have as many biopsies
as you can stand.

The way that "skin and subcutaneous tissue biospy and simple closure" is
coded for billing the insurance company, the first biopsy is full price and
each additional biopsy pays half of the first one. So on your visits, he
does one at full fee and one at half fee. When you come back, same thing. As
opposed to biopsying 20 at one time, where 19 of the moles would be biopsied
at half-fee. In this latter event, it gets to the point where it's not
cost-effective to see you - he would generate more fees relative to the time
spent by seeing some other patient.

HMc



From: SJ Doc on 14 Sep 2005 08:21
On Wed, 14 Sep 2005 07:28:43 GMT, "jay" wrote:

>Thanks for the reply. Yes, the excision was done simply by slicing
>off the moles and no stitches were required afterward, just a bandaid.
>y the way, I'm located in northeastern NJ.
>
>Thanks again,

Aw, hell. Another Yankees fan. I'm afraid that I haven't kept
current with the specialist services base up in Old East Jersey or
the sordid city across the Hudson, but I know that there will
definitely be SSO members in Bergen, Union, and Passaic
Counties. Not to mention the same sort of pigmented tumor
clinics in New York the Damned as can be found in University
City.

The only MedOnc guy I got to know while I was in training
up there moved (how coincidentally!) to Cherry Hill after
completing his fellowship at Sloan-Kettering. I still think I
ought to be receiving residuals on all the recruiting I've done
to pull colleagues out of that hellhole north of the Raritan
and down here into West Jersey.

Speaking of Memorial Sloan-Kettering Cancer Center, you
might want to check on information available from MSK
(see http://www.mskcc.org/mskcc/html/420.cfm) both for
more information on your disorder (and the options best
considered) as well as a conduit to the New York City
"family" of the SSO's Melanoma Mafia. What could it
hurt? Mayhap your family doctor has some knowledge
of "go-to" guys at MSK. If not, MSK has a "footprint" in
North Jersey (see http://www.mskcc.org/mskcc/html/662.cfm).
Far be it from me to recommend self-referral, but the MSK
guys have a pretty good reputation.

--------------------
Hygiene is the corruption of medicine by morality. It is
impossible to find a hygienist who does not debase his
theory of the healthful with a theory of the virtuous.
The whole hygienic art, indeed, resolves itself into an
ethical exhortation. This brings it, at the end, into
diametrical conflict with medicine proper. The true aim
of medicine is not to make men virtuous; it is to safeguard
and rescue them from the consequences of their vices. The
physician does not preach repentence; he offers absolution.

-- H.L. Mencken, The Smart Set, May 1919
 |  Next  |  Last
Pages: 1 2
Prev: Uterine leiomyosarcoma prognosis unduly optimistic?
Next: Aloe vera juice?