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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for tummy tuck surgery. Based on the medical documentation and photograph provided and review, an abdominoplasty is not medically necessary for treatment of this patients excess skin. The patient is noted to have an overhanging pannus with rashes. However, the medical documentation does not detail evidence of rashes or other findings to support a significantly chronic condition. The clinic notes do not reference chronic rashes underneath her abdominal pannus and the patients medication list does not include hydrocortisone cream or antibiotic ointment for her abdominal pannus. In addition, primary care documentation to support a chronic condition underneath her abdominal pannus was not provided. Moreover, the photograph shows evidence of a relatively mild overhang over the lower abdomen. Thus, the documentation does not demonstrate that the patient has evidence of chronic rashes that have failed reasonable conservative management. Therefore, the requested tummy tuck is not supported as medically necessary for treatment of this patients medical condition. With regard to the reconstructive nature of the requested procedure, the American Society of Plastic Surgeons states that 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. Further, researchers found that common functional problems associated with an overhanging pannus or skin redundancy may include disabling rashes, pain, physical limitation, back strain, and cosmetic deformity. This patient presents with a mildly abnormal abdominal pannus as the result of her weight loss. However, there is insufficient documentation from the patients providers to support that the patient has a significant functional impairment associated with her lower abdominal pannus that has failed reasonable conservative management. Overall, there is insufficient documentation to support that the requested surgery is would be performed to improve function. The patients appearance is normal for her size and weight based on review of the photograph. Although an abdominoplasty would provide more than a minimal improvement in the patients appearance, the photograph shows that any surgical treatment would be aesthetic in nature. All told, the requested tummy tuck is not reconstructive in nature for treatment of this patients medical condition. Final Result: The reviewer determined that the requested surgery is not medically necessary and is 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.