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

A 40-year-old female enrollee has requested excision, excessive skin and subcutaneous tissue of the: thigh (CPT 15832); buttock (15835); arm (15836); other area (15839); and mastopexy (19316) for treatment of her excess skin.  Findings:  The physician reviewer found that the overlap of the breasts, as seen in the photographs and documented clinically, is considered an abnormal enlargement of this area. Obesity can be considered a disease and would thus have led to the abnormal overlapping of the skin that worsens with correction of the underlying disease. The requested procedure of the breasts (mastopexy) is being performed to improve function and would create a normal appearance to the extent possible. The patient is documented by more than one provider to have functional problems as a result of the overlapping skin in this area. Although specific functional problems solely related to this area are not detailed, based on the photographs of the breasts, she is likely to have functional problems related to the overlap, and is an expected finding following this amount of weight loss. Moreover, the records describe the presence of functional problems including rashes, dermatitis, malodor, and discomfort with physical activity. As noted by the American Society of Plastic Surgeons (ASPS) on the difference between reconstructive and cosmetic surgery: When surgery to remove extensive skin redundancy and fat folds is performed solely to enhance a patients appearance in the absence of any signs or symptoms of functional abnormalities, the procedure should be considered cosmetic in nature and not a compensable procedure. Based on the documentation provided, there is inadequate evidence that the surgery is performed solely to enhance the patients appearance and rather is planned to improve functional problems for the breasts. The photographs show that the breasts are significantly overhanging. Attempts to treat functional problems associated with overlapping skin have been documented as well, including topical antibiotics, steroids and other creams. For these reasons, the requested mastopexy has been demonstrated to be reconstructive in nature and should therefore be approved. However, the patients thighs, buttock, arms, and other areas, display a milder abnormality. In the absence of greater detail of functional problems related to the other anatomic areas, the additional procedures are generally considered cosmetic. Based on the photographs of these other areas, as well as the areas not specifically viewed, one would consider the abnormalities mild and would require greater specific documentation of their exact functional problems. In summary, there are indications for medically necessary surgery for treatment of skin overlap following massive weight loss. Based on the photographs and overall clinical picture, the breasts display an abnormal condition. For the breasts, the requested surgery would be expected to provide more than a minimal improvement in function and appearance. For the other requested areas, the photographs display a milder condition and would not appear to offer more than a minimal improvement. Thus, the requested mastopexy (CPT 19316) is reconstructive in nature and should therefore be approved as medically necessary.