Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Arm lipodystrophy.
Treatment: Brachioplasty (19836-50).

The insurer denied Brachioplasty (19836-50).  The denial is upheld.

This adult female patient has arm lipodystrophy following massive weight loss. The loose arm skin exacerbates her fibromyalgia. She reports rashes in the arm skin despite topical medications.

The proposed brachioplasties are not medically necessary.

The records do not establish medical necessity for the proposed brachioplasties.  The patient's condition does not meet the American Society of Plastic Surgery criteria for third party coverage of skin resection following massive weight loss.  According to the American Society of Plastic Surgery Position Paper "Treatment of Skin Redundancy For Obese and Massive Weight Loss Patients" (1), "When surgery to remove extensive skin redundancy and fat folds is performed solely to enhance a patient's appearance in the absence of any signs or symptoms of functional abnormalities, the procedure should be considered cosmetic in nature and not a compensable procedure. For example, a panniculectomy to eliminate a large hanging abdominal panniculus and its associated symptoms would be considered reconstructive. In situations where a circumferential treatment approach is utilized to also treat the residual back and hip rolls or the ptotic buttock tissue, only the anterior portion of the procedures would be considered reconstructive, the remaining portion of the procedure would be considered cosmetic. 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 records do not note any rare circumstances that mandate treatment with brachioplasties. 

 According to a 2010 outcome analysis of brachioplasty surgery, "Patients report improvement in contour and self-esteem, and a high level of satisfaction with this procedure, despite the potential for an unfavorable scar."  This study found improvements in self-esteem and contour but did not describe functional benefits from brachioplasty surgery. 

According to Sergesketter et al.: "Brachioplasty has become one of the fastest-growing aesthetic surgery procedures, paralleling rising rates of weight loss surgery nationally."  

The patient is not sick from her excess skin, and has not had ulcerations, panniculitis or sepsis from her infections.  She has not required hospitalization or treatment with intravenous or oral antifungal or antibiotic medications.  Her excess skin has not jeopardized her health.  Physician supervised treatment is the simplest and safest method of managing this patient's problems, and conservative treatment with appropriate hygiene and topical medications has a reasonable likelihood of correcting her condition.  The records do not provide any objective medical documentation of infections or evidence that the patient has ever seen a physician for assistance with the medical management of infections.  The most appropriate treatment for this patient is an evaluation by a dermatologist or internist with appropriate, physician directed skin care.  Surgical lipectomy should be reserved for patients who have failed optimal medical management for intertrigo, which is not the case for this patient.