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

Findings:  The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for surgeries (CPT codes 15879 x 2 and 0232T followed by 15878 x 2 and 0232T) performed at separate stages. The records provided for review document that this patient presents with complaints of swelling and discomfort in the thighs, legs, ankles, arms, trunk, and buttocks. The patients provider has recommended staged procedures to address the patients diagnosis of lipedema. Peled and Kappos noted that lipedema is characterized by localized adiposity of the lower extremities, with extension of the adiposity from the hips to ankles that is typically unresponsive to attempts at weight loss. Patients also describe pain in the lower extremities, particularly with pressure, as well as easy bruising. One of the major distinguishing features of lipedema is the sparing of the feet, which can create a distinct step-off at the ankle. 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. Similar to lipedema, localized adiposity in some areas of the legs, particularly the outer thighs, around the knees, and the lower calves, can be resistant to diet and exercise in some patients. Reich-Schupke and colleagues noted that, 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. Treatment consists of four therapeutic mainstays including physical therapy, liposuction and plastic surgery, diet, and physical activity, as well as psychotherapy if indicated. When conservative measures are inadequate, surgical interventions are available. This patient complains of fatty nodules and pain rated 10/10 when the patient does not take supplements. The patient also reported that after the patient was unable to get out of bed for three days after jumping with the patient's child. Pain lasting for days after exercise is not characteristic of lipedema. The provider reports that the patient has lipedema. However, there is a lack of documentation of a physical examination supporting a diagnosis of lipedema. Further, the photographs provided for review did not demonstrate disproportionate findings consistent with lipedema. Based on the medical information received for review, a diagnosis of lipedema cannot be confirmed. Thus, the requested surgeries (CPT codes 15879 x 2 and 0232T followed by 15878 x 2 and 0232T) performed at separate stages are not medically necessary for 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; (2) To create a normal appearance, to the extent possible. The patients functional limitations do not have an established relation to the presence of lipedema. Furthermore, the information does not demonstrate that the patients appearance is not within the wide range of normal for a female. Thus, the requested staged surgical procedures are not being requested to improve function or to provide a more than minimal improvement in the patients appearance. For these reasons, the requested surgeries (CPT codes 15879 x 2 and 0232T followed by 15878 x 2 and 0232T) performed at separate stages are not reconstructive in nature for this patient. All told, the requested surgeries (CPT codes 15879 x 2 and 0232T followed by 15878 x 2 and 0232T) performed at separate stages are not medically necessary and not reconstructive in nature for treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary and not reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.