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

Nature of Statutory Criteria/Case Summary: The patient is status post massive weight loss with an extensive surgical history including a number of body contouring procedures. He has undergone the following surgical procedures: abdominoplasty, unspecified lipectomy, chest contouring, and body lift. The patient has also undergone several urologic procedures for treatment of multiple urethral strictures and incontinence, most recently undergoing a distal urothroplasty with penile rotation flap on 10/23/18. The patient reports that the skin redundancy interferes with his ability to urinate normally and maintain adequate hygiene. On 10/30/18, the patient was evaluated by a plastic surgeon who noted skin with normal coloration and turgor, no rashes, and no suspicious skin lesions. The genitalia were described as normal male external genitalia with sutures from recent distal urethroplasty. There was also excess skin noted lateral to the penile base as well as some excess volume/skin of the mons pubis. There were no signs of rashes, skin lesions, or breakdown. On 12/4/18, the patient was seen for a follow-up visit and the examination was noted to be unchanged from prior visit. Photographs reveal redundant and excess skin at the base of the penis, redundancy and laxity of the skin of the scrotum, fullness in the mons pubis, well-healed surgical incisional scars surrounding the mons pubis and peri-genital region, mainly laterally but not superiorly, and laxity and redundancy of the skin and subcutaneous tissues of the medial thighs. There is no skin or subcutaneous laxity or redundancy remaining on the lower abdomen following previous body contouring procedures. The glans penis is exposed, as is the urethral meatus, and there are no indications of chronic dermatitis of the distal penile skin leading to true buried penis, such as phimosis, balanitis, dermal edema or erythema, discharge, or other similar lesions. There is no indication of dermatitis, rash, breakdown, or other skin problem in the greater peri-genital regions surrounding the penis and scrotum. At issue in this case is whether soft tissue tightening around the penis and scrotum is medically necessary for the treatment of this patient and/or reconstructive in nature. The submitted documentation fails to demonstrate the medical necessity for the requested services. There is a lack of large randomized series reported addressing this specific issue of acquired buried penis and its surgical treatment, or any specific standard approach to this issue. Those series reporting reproducible success in such cases are a collaborative effort between plastic surgery and urology, and the patients treated in those series have significant functional impairment or comorbid conditions resulting from the skin excess. The issues surrounding urinary stream, spraying with urination, chronic moisture, and incontinence in this case are due to the patients multiple urological problems. Further, there is no evidence that these functional issues will be significantly improved with attempts at removal of skin. In this case, there is no documented history or photographic evidence of skin rashes, balanitis, phimosis, intertrigo, or other similar problems. Therefore, the requested soft tissue tightening around the penis and scrotum is not medically necessary.With regards to the requested soft tissue tightening around the penis and scrotum, the patients condition does constitute an abnormal structure of the body. It is not result of a congenital defect, a developmental abnormality, trauma, infection, tumors or disease. It is a normal structural change that is an accommodative response to gain or loss of body mass. The requested soft tissue tightening around the penis and scrotum is not likely to improve function or create a more than minimal improvement in the patients appearance. The appearance of this patient is normal and consistent with the gain and loss of weight. Therefore, the requested soft tissue tightening around the penis and scrotum is not reconstructive in nature.Final Result: The reviewer determined that the requested services are not medically necessary or 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 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.