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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for abdominoplasty provided, brachioplasty, fat injection to bilateral breasts, neck lift, and excision of gynecomastia for treatment of the enrollee, who is status post gastric bypass surgery. Findings:  The physician reviewer found that regarding the abdominoplasty performed, there is insufficient documentation of failed typical dermatologic measures.  The photographs only document mild lower abdominal excess.  The excess skin following significant weight loss is an abnormal occurrence.  Additionally, this was caused by the disease of obesity.  However, the abdominoplasty was not performed to either improve function or create a normal appearance to the extent possible.  The patient had a relatively normal appearance of the abdomen, and conservative treatment of the condition was not well-described.  As the patients condition was a relatively mild one, the planned procedure would not have made more than a minimal improvement in the appearance of this patient.  Therefore, the abdominoplasty was not reconstructive in nature and was not medically necessary for the treatment of this patient.The submitted documentation fails to demonstrate the medical necessity of brachioplasty in this clinical setting.  The records do not document clear evidence of a well-defined functional deficit related to the upper arms.  Additionally, the photographs do not depict a significantly abnormal condition of skin excess.  The procedure was not performed to either improve function or create a normal appearance to the extent possible, as the appearance was already relatively normal.  Per the records, the brachioplasty procedure was not likely to have produced more than a minimal improvement in the appearance of the patient.  Therefore, brachioplasty was not reconstructive in nature and was not medically necessary for the treatment of this patient.The records do not support the medical necessity of fat injection to bilateral breast.  The photographs do not depict a significantly abnormal condition of the breasts.  The documentation does not demonstrate that the fat injection to bilateral breasts was performed to either improve function or create a normal appearance to the extent possible.  There was no evidence that there was a functional deficit related to the breasts, and the breasts were already relatively normal.  Thus, fat injection to bilateral breast was not reconstructive in nature and was not medically necessary for the treatment of this patient.The documentation does not demonstrate the medical necessity of the neck lift.  There was no evidence of a functional compromise related to the neck, and the appearance was relatively normal.  The surgery was not likely to have provided more than a minimal improvement in the appearance of the patient, as his neck was already relatively normal for his age and gender.  Thus, the neck lift was not reconstructive in nature and was not medically necessary for the treatment of this patient.The records do not document the medical necessity of excision of gynecomastia.  There was no evidence of a functional compromise related to the breasts, and the appearance was relatively normal for his age and gender.  The procedure was not likely to have provided more than a minimal improvement in the appearance of the patient, as the breasts were already relatively normal.  Therefore, excision of gynecomastia was not reconstructive in nature and was not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were not reconstructive in nature and were 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.