Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Intertrigo and cellulitis
Treatment: Skin Excision
The insurer denied: Skin Excision
The denial is upheld.

The patient is an adult female. She has had a weight loss of 150 pounds and has kept it off for the past 3 years. She develops multiple infections along with intertrigo and cellulitis due to the moisture and infections between her legs and thigh area that become red and raw. She develops chronic vaginitis, and she treats with over-the-counter medication. She was prescribed Diflucan for the rashes. She is also using antifungal cream for the irritation and redness, but this does not help. She was put on antibiotics for infections in her thighs, but this does not help. The extra skin makes it very difficult to walk without pain and rubbing. Even after using powders, there is still a moisture and extreme chafing on her inner thighs. She has extreme pain in her thighs and buttocks and difficulty getting clothes to fit due to the excess skin on her thighs. Her surgeon recommends thighplasty.

The requested Skin Excision is not medically necessary.

The records do not establish medical necessity for the proposed thigh dermatolipectomies. The thigh dermatolipectomies are proposed as a treatment for recurrent infections, but the records do not include objective evidence to verify the accuracy of the patient's history. The patient does not have medical record documentation over time (e.g., series of office notes, dermatology consultations, pharmacy prescription records) of infections in the thigh folds, and photographs are black and white and do not show rashes. The letter from her physician describes a history of thigh infections, but the medical records do not provide any documentation in the form of frequent physician visits to the patient's PCP (primary care provider) or dermatologist for the management of ongoing clinically significant dermatologic problems that have either 1) never responded to topical therapy given or 2) despite initial response, have recurred and caused significant functional impairment.
The patient's condition also does not meet the American Society of Plastic Surgeons criteria for third party coverage of skin resection following massive weight loss. According to the ASPS (American Society of Plastic Surgeons) Position Paper "Treatment of Skin Redundancy For Obese and Massive Weight Loss Patients" (1), "When surgery to remove extensive skin redundancy and fat folds is performed solely to enhance a patient's 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." "Only in rare circumstances will buttock, thigh or arm lifts be needed to treat functional abnormalities. Typically, these procedures are performed to improve appearance and are therefore cosmetic in nature." The records do not document any rare circumstances that justify a thigh lift as a medically necessary procedure. Thigh lift is rarely performed for functional indications.
According to Shermak et al, "Thighlift can be a satisfying procedure for both the patient and surgeon because it provides aesthetic improvement in terms of skin excess and laxity." 
The most appropriate treatment for this patient is an evaluation by a dermatologist or internist with appropriate, physician directed skin care. Surgical lipectomy should be reserved for patients that have failed optimal medical management for intertrigo, which is not documented to be the case for this patient. Summary treatment letters and patient appeal testimonies in the absence of physician office note documentation of specific dates of treatments and medications prescribed do not provide sufficient documentation to confirm the failure of medically supervised care.