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

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for brachioplasty surgery to remove excessive tissue under the arms. The enrollee has excessive and redundant skin and soft tissue of her arms resulting from massive weight loss. The enrollee is status-post panniculectomy and has done extremely well. She reports clothing is constrictive around her arms due to the excessive skin and she has difficulty with exercise, and hygiene. The excess skin is causing pain and is requiring relief from muscle relaxants. She describes how the excess skin creates a risk for injury at work. She is concerned these issues may also pose a risk to her employment status because the pain is so severe. Is the requested surgery performed to do either of the following: improve function or create a normal appearance to the extent possible? Does the surgery provide more than a minimal improvement in the appearance of the enrollee? The enrollee underwent weight loss surgery and has since lost over 120 pounds. She underwent abdominal panniculectomy with good results. The enrollees current issues are related to large amounts of excess skin under her arms. Although the extra skin may be uncomfortable, it does not constitute a medical condition that must be addressed with surgery. It is very unlikely and uncommon to see complications of the extra skin under the arms, which require hospitalization, antibiotics or wound care. There is insufficient evidence in the record of infection, cellulitis, ulcers or irritation. The medical literature indicates there are limitations to brachioplasty. The resulting scar is prone to widening and hypertrophic transformation. The exposed area of the inner arm cannot be easily hidden. It can be a source of significant dissatisfaction for the enrollee and the practitioner. An outcome analysis found improvements in self-esteem and contour but did not describe functional benefits from brachioplasty surgery. The optimal method for treatment of upper arm fat removal and skin tightening has not been achieved. Current methods can result in dangerous complications and do not always result in an appealing appearance. Having a large amount of skin under the arms does not constitute an abnormal structure of the body. There is no history of trauma, infections, cancer, tumors or disease causing this extra skin; only obesity. The extra skin was present before weight loss as the result of skin stretching due to obesity. The requested surgery, brachioplasty, will not improve function in a measurable way, and will not create a normal appearance, because the current appearance is not abnormal. In this case, surgery is not reconstructive and will not result in more than a minimal improvement in the appearance of the enrollee. Anatomically and functionally, surgery will not improve range of motion, activity, strength, function or appearance of the arms.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition.Credentials/Qualifications: The physician 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 similar medical condition.