Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Excess skin of thigh and excessive and redundant 
skin and subcutaneous tissue
Treatment: Removal of Excess Skin
The insurer denied: Removal of Excess Skin
The denial is Upheld

This adult female patient had weight loss of 170 pounds and has kept it off for the past three years. She underwent thigh lift surgery. According to her surgeon, the patient still has rashes in her gluteal cleft and excess skin on her hips and thighs bilaterally. Her surgeon recommends revision thighplasty done for both the outer thighs as well as the hip area. The patient develops rashes and irritation in the buttock area due to the excess skin. She has difficulty getting clothes to fit due to the excess skin on her thighs and hip area. Her surgeon recommends thighplasty with removal of the excess skin on her hips.

The proposed treatment is not medically necessary.

These procedures are not medically necessary. The patient has generalized skin laxity consistent with the history of massive weight loss. Correction of skin laxity following massive weight loss is generally considered cosmetic in the absence of clear and compelling documentation of specific signs and symptoms that 1) are clearly related to the excess skin 2) are health threatening or cause significant functional disability and 3) have failed to improve despite reasonable attempts at conservative therapy. A reasonable standard for evaluating the medical necessity of potentially cosmetic surgery is whether the submitted records include convincing and confirmatory evidence of a chronic functional problem that has failed reasonable attempts at conservative therapy. These proposed procedures do not meet this standard. The patient does not have medical record documentation over time (e.g., series of office notes, dermatology consultations, pharmacy prescription records) of skin fold, and photographs documenting cellulitis, ulcerations or rashes are not submitted. In addition, the medical records do not provide any documentation in the form of primary care physician (PCP) or dermatology progress notes that describe 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 does not meet the American Society of Plastic Surgeons (ASPS) criteria for third party coverage of skin resection following massive weight loss. According to the American Society of Plastic Surgeons Position Paper "Treatment of Skin Redundancy Following Massive Weight Loss", skin resection is medically necessary if "panniculitis or uncontrollable intertrigo is present. 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 panniculitis or the failure of medically supervised conservative therapy to control this patient's intertrigo. Surgical lipectomy should be reserved for patients that have failed optimal medical management for intertrigo, which is not documented to be the case for this patient. Summary treatment letters and member 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.