Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Skin laxity.
Treatment:  Skin Surgery, Belly and Chest procedure.

The insurer denied coverage for the Skin Surgery, Belly and Chest procedure.  The denial is upheld. 

This is a male patient with a history of obsessive compulsive disorder (OCD), dysthymia, and general anxiety disorder.  As per an office visit note, the patient has excess hanging skin due to drastic weight loss.  The patient is requesting removal of excess skin because it is causing skin irritation and is exacerbating his OCD symptoms. 

Based on the review of the medical record and literature, removal of excess breast and abdominal skin is not medically necessary.  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.  

In this case the requested procedures do not meet this standard for medical necessity.  The patient does not have medical record documentation over time (e.g., series of office notes, dermatology consultations, and pharmacy prescription records) of skin fold, and the submitted photos do not show cellulitis, ulcerations or rashes.  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 never responded to topical therapy given or 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 ASPS Position Paper on "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 submitted records for this case do not document panniculitis or the failure of medically supervised conservative therapy to control this patient's intertrigo.  The patient is not sick from his excess skin, and has not had ulcerations, panniculitis or sepsis.  A dermatologist has not evaluated him for rashes.  The patient has not required hospitalization or treatment with need for intravenous (IV) or oral antifungal or antibiotic medications.  The patient's excess skin has not jeopardized his health.  Surgical lipectomy should be reserved for patients that have failed optimal medical management for intertrigo, which is not documented to be in this case for this patient.  

Thus, the Skin Surgery, Belly and Chest procedure is not considered medically necessary for this patient.

The health plan acted reasonably, with sound medical judgment, and in the best interest of the patient.

The carrier's denial of Skin Surgery, Belly and Chest should be upheld.  The medical necessity is not substantiated.