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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for removal of excessive loose skin (in the suprapubic/genital area).At issue is whether the requested removal of excessive loose skin (in the suprapubic/genital area) is medically necessary for treatment of the patients medical condition. Does the condition constitute an abnormal structure of the body? If so, is the abnormal structure of the body caused by any of the following: congenital effects, developmental abnormalities, trauma, infection, tumors, or disease? If so, is the requested surgery performed to do either of the following: improve function or create a normal appearance to the extent possible? If so, does the surgery provide more than a minimal improvement in the appearance of the patient?Smith-Harrison and colleagues state, Acquired buried penis (ABP) is a urologic condition that has significant morbidity and negative effect on quality of life, including but not limited to sexual function, hygiene, micturition, and self-image. Mirastschijski states, The adult buried penis (BP) is associated with obesity or found in patients after massive weight lossIn post bariatric patients, the penis is not engulfed into the prepubic tissue. In contrast to highly obese patients, the BP is covered underneath the cutaneous apron. In this case, the patient has loose pubic skin following massive weight loss and two lower abdominoplasties. Physical examination on 8/17/21 reported no frank panniculus of the abdomen and no overhang of tissue in genital area. The patient demonstrates that skin in the pubic area can be stretched to cover the length of the penile shaft, but there is no report or documentation that there is any interference with urinary or sexual function. There is no medical report of skin infection or intertrigo in the genital area in the medical records received for review. Therefore, the requested removal of excessive loose skin (in the suprapubic/genital area) is not medically necessary for treatment of the patients medical condition. The California Reconstructive Surgery Statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) To improve function. (2) To create a normal appearance, to the extent possible.Excess pubic skin following massive weight loss is not an abnormal structure of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease. It is a normal structural change that is an accommodative response to gain or loss of body mass. Loss of function due to skin infection, urinary obstruction or sexual function is not documented in the medical information received for review. The California Reconstructive Surgery Statute does not apply to the patient at this time. Therefore, the requested removal of excessive loose skin is not reconstructive in nature.Final Result: The reviewer determined that the requested service is 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.