Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bilateral thigh lipodystrophy and skin ptosis with 
intertrigo
Treatment: Bilateral Thigh Lift (15832-50)
The insurer denied: Bilateral Thigh Lift (15832-50)
The denial is upheld.

The patient is an adult female. She had a bilateral breast reduction, bilateral brachioplasty and lateral chest resection eight months ago. Her current status is 167 pounds and BMI (body mass index) 26.95. Her weight has been stable for greater than one year. Despite diet and exercise, the patient has persistent bilateral thigh ptosis and lipodystrophy. The patient has currently lost 311 pounds from her highest weight. She has osteoarthritis (bone on bone of her knees). She has been told that for each excess pound on the body, is the equivalent of 4 pounds of pressure on the joints. She notes that these are not small masses/deposits on her thighs. She also receives gel injections every 6 months for this issue. The patient exercises every day, and she notes that her thighs are an issue with walking, and that the weight of them pulling and swinging back and forth is painful and pulls down on her groin area. She also has sores and rashes in the skin folds. It is noted that these masses cannot be lost working out in a gym or through diet. They will only worsen. She reports an inability to attend to daily activities and difficulty with clothing because of her excess thigh skin. She notes poor posture and balance secondary to her bilateral thigh deformity. During the summer, she has increased incidence of skin crease dermatitis treated with topical ointment. Despite diet and exercise, she is unable to reduce the size of her thighs or alleviate any symptoms. The patient states alternative treatments such as compressive garments do not have significant relief of her chronic symptoms. On examination, the patient is noted to have bilateral thigh lipodystrophy and skin ptosis with intertrigo. Her surgeon recommends bilateral thighplasty.

The Bilateral Thigh Lift (15832-50) is not medically necessary.

The patient reports that her thigh skin and fat is exacerbating her knee arthritis, but peer-reviewed literature does not support thigh lift surgery as a treatment for knee arthritis. The patient also complains of rashes due to her excess thigh skin. 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, and 
photographs are black and white and do not show rashes. 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 PCP (primary care provider) 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. The records do not document any rare circumstances that justify a thigh lift as a medically necessary procedure. 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.