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

An enrollee has requested authorization and coverage for abdominoplasty for treatment of the enrollees medical condition. Findings:  The physician reviewer found that there is a lack of support in the medical literature for the requested services in this clinical setting. Overall, the patient has well-documented evidence of chronic back and abdominal pain but it is unclear if abdominal muscle plication would likely correct her functional deficit of pain. The repair of diastasis recti is not generally considered to be a functional treatment but can be an integral part to cosmetic procedures, namely abdominoplasty. In evaluating functional status following abdominoplasty, rectus plication did not significantly improve functional outcomes.  There is some indication that muscle plication may affect intractable lower back pain.  However, the authors noted that non-operative therapy and significant work-up to identify other reasons for the pain should be evaluated prior to abdominoplasty with muscle plication.  In this patient, she presents with some evidence of chronic back and abdominal pain. However, the submitted records do not demonstrate that sufficient work-up of the pain and conservative management have been exhausted. The patient was recommended for physical therapy and weight loss, which does not appear to have been completed.  Overall, the repair of diastasis recti is not well-recognized as a procedure that improves functional impairment.  Also at issue is whether the requested abdominoplasty qualifies as reconstructive surgery. First, does the condition constitute an abnormal structure of the body? The patient has evidence of diastasis recti which can be considered an abnormal separation of the rectus muscles. If so, is the abnormal structure of the body caused by any of the following: congenital defects, developmental abnormalities, trauma, infection, tumors or disease? One could consider diastasis recti a result of trauma from pregnancy and/or weight gain. If so, is the requested surgery being performed to either improve function or create a normal appearance to the extent possible?  The patients condition does not meet these criteria as there is a lack of consensus from the medical literature that treatment of diastasis recti improves function. There may be rare cases when this is true, but conservative management and other work-up should be comprehensive, which is lacking in this patients case. Further, based on the photographs provided, the patient's current appearance may be consistent with her weight and not necessarily a result of her rectus diastasis. As such, it has not been established that the requested service will create a normal appearance to the extent possible. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition and are not reconstructive in nature. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer number one 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.