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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for four to five suction-assisted liposuction procedures with manual extraction of nodules. Findings:  The physician reviewer found that lipedema is characterized by localized adiposity of the lower extremities, often occurring in females with a family history of the condition. The adiposity extends from hips to ankles and is typically unresponsive to weight loss. Patients report pain in the lower extremities, particularly with pressure, as well as easy bruising. Distinguishing lipedema from other conditions causing fatty excess in the lower extremities can be difficult. 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. Reich-Schupke and colleagues state that the diagnosis of lipedema is established on the basis of medical history and clinical findings. The authors commented that most often there is a localized, symmetrical increase in subcutaneous adipose tissue in arms and legs that is in marked disproportion to the trunk. Treatment options include complex physical therapy, liposuction and plastic surgery, diet, and physical activity, as well as psychotherapy. Surgical procedures are indicated for patients with persistent or progressive symptoms despite adequate conservative therapy. This patient presents with complaints of constant body pain 8/10, that she reports is only improved by lying down. The provider noted that the patient is extremely obese. The records do not report the patients current weight. In addition, the last report of a medical visit for weight loss was in 2010. Photographs are limited to the lower extremities and do not show evidence of cuffing. Markedly disproportionate obesity in the lower extremities is not confirmed by the medical information received for review. A diagnosis of clinically significant lipedema as compared with extreme exogenous obesity is not supported by the available documentation. For these reasons, the requested four to five suction-assisted liposuction procedures with manual extraction of nodules are not medically necessary to treat the patients medical condition.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. A diagnosis of clinically significant lipedema is not confirmed by the medical information received for review. Exogenous obesity is not a result of a congenital defect, a developmental abnormality, trauma, infection, tumor, or disease. Moreover, exogenous obesity is not an abnormal structure of the body, rather it is a normal structural change that is an accommodative response to gain or loss of body mass. The appearance of the patient is within normal range and consistent with the gain and loss of weight. The requested procedure is not requested to improve function or provide a more than minimal improvement in the patients appearance. All told, the requested four to five suction-assisted liposuction procedures with manual extraction of nodules is 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. 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.