Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for excess thigh skin removal. The records do not establish the medical necessity for the proposed thigh dermatolipectomies. The thigh dermatolipectomies are proposed as a treatment for recurrent infections, but the records do not include objective evidence of recurrent infections in the patients history. Specifically, the medical records do not include office notes, dermatology consultations, and prescription records for treatment of infections in the thigh folds. Moreover, photographs documenting cellulitis, ulcerations, or rashes were not submitted for review. The letter from the patients provider describes a history of thigh infections but problems with thigh infections are not mentioned in any of the multiple providers clinical notes provided for review. The medical records do not provide any documentation in the form of frequent visits to the patients provider for the management of ongoing clinically significant dermatologic problems that have either not responded to topical therapy or despite initial response, have recurred and caused significant functional impairment. The patients condition also does not meet the researchers criteria for third party coverage of skin resection following massive weight loss. Thus, the requested excess thigh skin removal is not supported as medically necessary. According to the researchers, when surgery to remove extensive skin redundancy and fat folds is performed solely to enhance a patients appearance in the absence of any signs or symptoms of functional abnormalities, the procedure should be considered cosmetic in nature and not a compensable procedure. Further, a thigh lift is rarely performed for functional indications. The patient does present with an abnormal condition with excess skin as a result of weight loss. However, the patient is not sick from her excess skin, and has not had ulcerations, panniculitis or sepsis from her infections. She has not required hospitalization or treatment with intravenous or oral antifungal or antibiotic medications. Her excess thigh skin has not jeopardized her health. Physician supervised treatment is the simplest, safest, and most effective method of managing this patients problems, and conservative treatment with appropriate hygiene and topical medications has a reasonable likelihood of correcting her condition. Surgical lipectomy is reserved for patients that have failed optimal medical management for intertrigo, which is not the case for this patient. Thus, the requested surgery has not been recommended to treat a functional problem and is not expected to make more than a minimal improvement the patients appearance. For these reasons, the requested excess thigh skin removal is not reconstructive in nature or medically necessary. Final Result: The reviewer determined that the requested surgery is not medically necessary and is not reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in ** and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.