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

A 44-year-old female enrollee has requested coverage for a past abdominoplasty, umbilical herniorrhaphy, and bilateral breast augmentation with mastopexy surgery for treatment of her medical condition status post two Cesarean section births.  Findings:  The physician reviewer found that based on review of the available records, the patient has a documented umbilical hernia, which is considered an abnormal opening of the abdominal wall at the location of the umbilical stalk. The umbilical hernia can be caused by a congenital defect or by a developmental abnormality. This patients umbilical hernia was noted to be causing discomfort, thus correction would be primarily to improve function. The American Society of Plastic Surgeons (ASPS) indicates that a hernia repair requires dissection and definition of the fascial defect, which is included in the operative note from the patients plastic surgeon. In addition, a hernia can become incarcerated and could cause significant functional problems and thus correction could be considered functional as well. For these reasons, the umbilical herniorrhaphy was reconstructive in nature and therefore medically necessary. The patients breasts show an appearance consistent with pseudoptosis and a relatively common, but unwanted, nipple position following a breast reduction. The breast deformity is a type of acquired appearance as a result of surgery. It is unclear the cause of the patients condition that led to the original breast reduction. The medical records do not describe the reasons for the original breast reduction. The correction of breast ptosis with augmentation and mastopexy would not be considered functional as the medical documentation does not support any functional problem. Further, relatively abnormal nipple position can be a complication or an unwanted result from a breast reduction. Even though the augmentation mastopexy corrected this result, one would still consider the correction especially with an added augmentation a cosmetic and non-reconstructive surgery (Spear, et al). Consistent with the ASPS guidelines, the bilateral breast augmentation with mastopexy surgery was to create an improved appearance beyond what one would consider normal, and therefore was not reconstructive in nature or medically necessary.  Similarly, the patients abdomen preoperatively does not constitute an abnormal structure but rather weakness of a normal structure as commonly seen following pregnancy or with age. In addition, there is no medical documentation that the abdominoplasty was performed for functional reasons. Functional concerns that can be present include intertrigo, pain or ulceration. None of these were documented in the patients records and the photographs do not support this as well. The conditions are not to a severity to warrant reconstructive corrections. The abdominoplasty and muscle plication is a well-known cosmetic surgery in this setting, as described by the ASPS. Based on the photographs and the medical record, this is a non-reconstructive procedure. The findings and photographs do not support that the patient has a significantly abnormal appearance, but that the surgeries are aimed at improving the relatively normal appearance. In summary, the umbilical hernia treatment would be considered a functional procedure and reconstructive in nature. The bilateral breast augmentation with mastopexy surgery and abdominoplasty are consistent with cosmetic procedures and should not be considered reconstructive or medically necessary.