Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested bilateral arm lift (brachioplasty), breast lift (mastopexy), thigh lift (thighplasty), and panniculectomy for treatment of the enrollees weight loss status post bariatric surgery.  Findings: The physician reviewer found that the records indicate that this patient experienced significant weight loss following bariatric surgery. Based on the documentation provided, a clear functional deficit has not been defined related to her excess soft tissue and skin overlap of the arms, breasts, abdominal pannus and thighs. Photographs show evidence of mild soft tissue excess of the arms, Grade II/III ptosis of the breasts, an overhanging lower abdominal pannus and severe soft tissue excess of the thighs. Therefore, as a well-defined functional deficit has not been adequately defined, and the requested procedures are not supported as medically necessary based on a functional compromise. However, reconstructive surgery can be extended to cases in which there is a significant abnormality or deformity. The American Society of Plastic Surgeons (ASPS) state 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. Cosmetic surgery is surgery that is performed to alter or reshape normal structures of the body in order to improve appearance. Reconstructive surgery is surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease in order to improve function or to create a normal appearance, to extent possible.Based on review of the photographs, the patient has abnormal excess skin of the arms, breasts, and abdomen, as well as a severely abnormal condition of the thighs. The patient had a condition of significant obesity, which is considered a disease. Treatment of this condition has led to her abnormal condition of excess skin. With respect to the arms, breasts and abdomen, the conditions are only mildly abnormal in appearance. However, she has a significant abnormal condition associated with her thigh excess. Further, surgical intervention would provide a more than minimal improvement in the patients appearance. Thus, correction of the patients excess skin on the thighs is considered reconstructive in nature and therefore medically necessary. Accordingly, the requested thighplasty is supported as reconstructive in nature and medically necessary while the requested bilateral brachioplasty, mastopexy, and panniculectomy are not reconstructive in nature and not medically necessary.Final Result: The reviewer determined that a portion of the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.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.