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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bilateral brachioplasty (CPT 15836) and bilateral thighplasty (CPT 15832). Findings:  The physician reviewer found that The submitted documentation fails to demonstrate the medical necessity of the requested bilateral brachioplasty (CPT 15836). Photos show skin excess on the medial thighs and arms. The patient complains of a recurrent rash under the loose skin of her arms and thighs. The patient uses over-the-counter creams, which she states are partially effective. The presence of fungal rashes is not documented on any medical examination. Therefore, the requested bilateral brachioplasty (CPT 15836) is not medically necessary.With regards to the requested bilateral brachioplasty (CPT 15836), the patients condition does not constitute an abnormal structure of the body. Excess skin on the medial arms is not a result of a congenital defect, a developmental abnormality, trauma, infection, tumors or disease. It is a normal structural change that is an accommodative response to gain or loss of body mass. The requested bilateral brachioplasty (CPT 15836) is not likely to improve function or create a normal appearance to the extent possible. The appearance of the patient is normal and consistent with the gain and loss of weight. Therefore, the requested bilateral brachioplasty (CPT 15836) is not reconstructive in nature.The clinical notes do not demonstrate the medical necessity of the requested bilateral thighplasty (CPT 15832). Photos show skin excess on the medial thighs and arms. The patient complains of a recurrent rash under the loose skin of her arms and thighs. The patient uses over-the-counter creams, which she states are partially effective. The presence of fungal rashes is not documented on any medical examination. The patient does not have a functional problem with a rash that has been documented or demonstrated to be resistant to appropriate medical treatment. Thus, the requested bilateral thighplasty (CPT 15832) is not medically necessary.With regards to the requested bilateral thighplasty (CPT 15832), the patients condition does not constitute an abnormal structure of the body. Excess skin on the medial thighs is not a result of congenital defect, a developmental abnormality, trauma, infection, tumors or disease. The excess skin is not an abnormal structure of the body. It is a normal structural change that is an accommodative response to gain or loss of body mass. The requested bilateral thighplasty (CPT 15832) is not likely to improve function or create a normal appearance to the extent possible. The appearance of the patient is normal and consistent with the gain and loss of weight.  Therefore, the requested bilateral thighplasty (CPT 15832) is not reconstructive in nature.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.