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

Findings:  The physician reviewer found that The patient has requested authorization and coverage for liposuction surgery. Warren Peled and Kappos state, Lipedema is an uncommon disorder characterized by localized adiposity of the lower extremities, often occurring in females with a family history of the condition. The adiposity extends from hips to ankles and is typically unresponsive to weight loss. In addition to the aesthetic deformity, women also describe pain in the lower extremities, particularly with pressure, as well as easy bruising. Although the condition is well described, it is relatively rare and often misdiagnosed. The authors further note, Distinguishing lipedema from other conditions causing fatty excess in the lower extremities can be difficult. Making the diagnosis relies on some of the hallmark characteristics of lipedema, such as the easy bruising and pain with soft tissue pressure, as well as the step-off at the ankles. Women with generalized obesity typically do not have these history and physical exam characteristics. Additionally, although many patients with lipedema may also be overweight, those who have tried to lose weight through diet and exercise typically find that reducing the size of their legs is very challenging, which is often not the case in women with standard obesity. This distinction is less clear, however, in women who have localized adiposity in the lower extremities that is not due to lipedema. Similar to lipedema, localized adiposity in some areas of the legs, particularly the outer thighs, around the knees, and the lower calves, can be very resistant to diet and exercise in some women. Further, some women with lipedema may also have additional areas of localized adiposity, making the diagnosis even more challenging.Reich-Schupke and colleagues state, The diagnosis [of lipedema] is established on the basis of medical history and clinical findings. Characteristically, there is a localized, symmetrical increase in subcutaneous adipose tissue in arms and legs that is in marked disproportion to the trunk. Other findings include edema, easy bruising, and increased tenderness. Further diagnostic tests are usually reserved for special cases that require additional workup. Lipedema is a chronic, progressive disorder marked by the individual variability and unpredictability of its clinical course. Treatment consists of four therapeutic mainstays that should be combined as necessary and address current clinical symptoms: complex physical therapy (manual lymphatic drainage, compression therapy, exercise therapy, and skin care), liposuction and plastic surgery, diet, and physical activity, as well as psychotherapy if necessary. Surgical procedures are indicated if  despite thorough conservative treatment  symptoms persist, or if there is progression of clinical findings and/or symptoms. If present, morbid obesity should be therapeutically addressed prior to liposuction. In this case, the patient has a history of severe obesity treated with laparoscopic gastric sleeve. The patient's weight went from 233 pounds preoperatively to a low of 173 postoperatively. The records noted that the patient's weight had been stable at 218 pounds, with a BMI of 38.66 kg/m2, for the past three years. The patient reports severe pain that is excruciating to the touch and feels like deep bruising. Photographs submitted for review showed generalized obesity, some disproportionate obesity as the arms are significantly less obese than the rest of the body, and ankle cuffing. Given that the ankle cuffing and disproportionate obesity present in the submitted photographs is consistent with a diagnosis of lipedema, the requested service is medically indicated. Therefore, liposuction surgery is medically necessary for the treatment of this patient.The California reconstructive surgery statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function; or (2) to create a normal appearance, to the extent possible. In this case, lipedema fat is an abnormal structure of the body caused by a developmental defect. The lipedema interferes with function by causing pain, and the requested surgery is expected to improve function by relief of pain. Accordingly, the requested liposuction surgery is reconstructive in nature for treatment of this patient in order to improve the patients function.Final Result: The reviewer determined that the requested service is medically necessary for treatment of the patients medical condition and is reconstructive in nature. Therefore, the Health Plans denial should be overturned.