Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skin Disorders. 
Treatment: Surgical Services (All). 
The insurer denied suction assisted lipectomy, upper extremity for medical necessity. 
The denial was upheld. 

This patient is a female with a past medical history of bariatric sleeve gastrectomy and status/post (s/p) mastopexy. She now has symptomatic excessive upper arm skin following massive weight loss. She has complaints of rashes, skin breakdown and difficulty wearing clothing. Topical medications have not improved her symptoms. Her weight has been stable for six months, after losing 105 pounds following her surgery. Surgical excision of the excess upper arm skin is planned.
At issue is the medical necessity of suction assisted lipectomy, upper extremity.

The health plan's determination of medical necessity is upheld in whole.

The requested health service/treatment of suction assisted lipectomy; upper extremity is not medically necessary for this patient.
The records do not establish medical necessity for the proposed suction assisted lipectomy brachioplasties. The suction assisted lipectomy brachioplasties are proposed as a treatment for recurrent infections. The patient does not have medical record documentation over time (e.g., a series of office notes, dermatology consultations) of skin infections in the arm folds, and photographs documenting cellulitis, ulcerations or rashes are not submitted.
The patient's condition does not meet the American Society of Plastic Surgery criteria for third party coverage of skin resection following massive weight loss. According to the American Society of Plastic Surgery, "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. For example, a panniculectomy to eliminate a large hanging abdominal panniculus and its associated symptoms would be considered reconstructive. In situations where a circumferential treatment approach is utilized to also treat the residual back and hip rolls or the ptotic buttock tissue, only the anterior portion of the procedures would be considered reconstructive, the remaining portion of the procedure would be considered cosmetic. 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." [1] The records do not indicate any rare circumstances that mandate treatment with brachioplasties. According to a 2010 outcome analysis of brachioplasty surgery, "Patients report improvement in contour and self-esteem, and a high level of satisfaction with this procedure, despite the potential for an unfavorable scar." [3] This study found improvements in self-esteem and contour but did not describe functional benefits from brachioplasty surgery. Surgical lipectomy should be reserved for patients that have failed optimal medical management for intertrigo.
Therefore, the suction assisted lipectomy; upper extremity is not medically necessary.