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

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for suction assist lipectomy of the lower extremity. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the patients left knee pain and discomfort with genu valgus deformity and are not reconstructive in nature. This patient has well-documented evidence of primary chronic left knee pain associated with valgus alignment, mild lipodystrophy of the upper thighs, a history of morbid obesity, with constant trauma on the medial knees. However, the documentation does not indicate chronic intertrigo, dermatitis or injury and fails to adequately support that liposuction would directly improve the patients left knee condition. The photographs that were submitted are supportive of a relatively mild condition and do not establish that liposuction of this condition would have any effect on the patients overall chronic left knee pain. While a study found there can be indication for liposuction as a functional treatment for lymphedema, the submitted orthopedic documentation is consistent with a primary left knee condition associated with the patients valgus alignment and fails to adequately support that liposuction would improve the patients left knee condition. The patients primary diagnosis is chronic left knee pain and based on the documentation provided; this is mainly a problem of the knee and not as the result of the mild lipodystrophy of the thighs. In addition, the plastic surgeons examination detail, as well as others, do not support that there is chronic dermatitis as the result of constant trauma or pressure. If the patient had ongoing trauma, one would expect to see evidence of chronic injury on examination. Therefore, as it has not been established that liposuction of the thighs/knee would provide reasonable benefit, the requested services are not considered medically necessary. With regard to whether the requested services are considered reconstructive in nature, based on the records provided, the patient has abnormal fat accumulation of the thighs, which is considered an abnormal structure of the body. This can be considered a developmental abnormality of lipodystrophy accumulation of the thighs caused by obesity, which is a disease. However, there is not a clear indication that the requested services would improve the patients function. Additionally, the patients appearance is normal with only mild excess skin. Therefore, the requested services are not likely to create a more normal appearance to the extent possible. Based on the photographs submitted, the requested services are not likely to provide more than a minimal improvement in appearance. Liposuction would only provide a relatively mild improvement on a normal appearance.  In sum, the requested suction assist lipectomy of the lower extremity is not reconstructive in nature.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in plastic surgery 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.