Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Status post bariatric surgery
Treatment:  Thighplasty
The thighplasty is not medically necessary.

This female has lost 130 pounds following bariatric surgery.  She has excess thigh skin that is causing recurrent rashes and interferes with ambulation.  Photos show a female with excess thigh skin and fat.  Thigh lipectomies are planned.

The records do not establish 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 to verify the accuracy of the patient's history.  The patient does not have medical record documentation over time (e.g., series of office notes, dermatology consultations, pharmacy prescription records) of infections in the thigh folds.  The letter from her physician describes a history of thigh infections, but the medical records do not provide any documentation in the form of frequent physician visits to the patient's primary care physician (PCP) or dermatologist for the management of ongoing clinically significant dermatologic problems that have either 1) never responded to topical therapy given or 2) despite initial response, have recurred and caused significant functional impairment.

The patient's condition also does not meet the American Society of Plastic Surgeons criteria for third party coverage of skin resection following massive weight loss.  According to the ASPS Position Paper "Treatment of Skin Redundancy For Obese and Massive Weight Loss Patients"(1), "When surgery to remove extensive skin redundancy and fat folds is performed solely to enhance a patient's 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.  For example, a panniculectomy to eliminate a large hanging abdominal panniculus and its associated symptoms would be considered reconstructive.  In situations where a circumferential treatment approach is utilized to also treat the residual back and hip rolls or the ptotic buttock tissue, only the anterior portion of the procedures would be considered reconstructive, the remaining portion of the procedure would be considered cosmetic.  Only in rare circumstances will buttock, thigh or arm lifts be needed to treat functional abnormalities.  Typically these procedures are performed to improve appearance and are, therefore, cosmetic in nature."  The records do not document any rare circumstances that justify a thigh lift as a medically necessary procedure.  Thigh lift is rarely performed for functional indications.  According to Shermak et al, "Thighlift can be a satisfying procedure for both the patient and surgeon because it provides aesthetic improvement in terms of skin excess and laxity."  

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 (IV) or oral antifungal or antibiotic medications.  Her excess thigh skin has not jeopardized her health.  Physician supervised treatment is the simplest, safest and most cost-effective method of managing this patient's problems, and conservative treatment with appropriate hygiene and topical medications has a reasonable likelihood of correcting her condition.  The most appropriate treatment for this patient is an evaluation by a dermatologist or internist with appropriate, physician directed skin care.  Surgical lipectomy should be reserved for patients that have failed optimal medical management for intertrigo, which is not the case for this patient.  Summary treatment letters and patient appeal testimonies in the absence of physician office note documentation of specific dates of treatments and medications prescribed do not provide sufficient documentation to confirm the failure of medically supervised care.