Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for suction-assisted lipectomy on trunk and upper extremities. The records provided for review document that this patient has a diagnosis of stage 1 lipedema. The provider charted that the patients lipedema involves the arms and abdomen in addition to the legs. The patient has been approved for liposuction of the lipedema of the legs. She underwent a functional evaluation, which noted the impact of the lipedema on the patients upper extremities and trunk. She also noted pain in her arms. Consensus and peer-reviewed literature have demonstrated the benefits of liposuction for patients with lipedema in terms of pain and quality of life. As noted by Aksoy and colleagues, Currently the only effective treatment to reduce pain sensations in lipedema and prevent progression of the disease is microcannular tumescent liposuction. In this case, the patient has lipedema that is described as extremely painful. Additionally, the literature supports an increased benefit with treatment at earlier stages, as in the case in this patient. On review of the available documentation, this patient meets the criteria from the U.S. consensus paper discussed by Herbst and colleagues. The authors noted that the indications for lipedema reduction surgery include a diagnosis of lipedema with demonstrated compliance and adherence to, and failure of, conservative therapies. Furthermore, the authors stated that lipedema reduction surgery may be less effective in patients with advanced stages of lipedema. This patient presents with an early stage of lipedema, which is more likely to respond well to the requested surgical interventions. Therefore, the requested suction-assisted lipectomy on trunk and upper extremities is medically necessary for treatment of this patient. The California reconstructive surgery statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function; or (2) to create a normal appearance, to the extent possible. This patients records document the presence of an abnormal structure of the body due to disease. The requested surgery is being performed to improve the patients function. A decrease in function is documented in the patients functional capacity evaluation for arms, legs, and core. Given this support, the requested suction-assisted lipectomy on trunk and upper extremities is reconstructive in nature for treatment of this patient. All told, the requested suction-assisted lipectomy on trunk and upper extremities is medically necessary and reconstructive in nature for treatment of this patient.Final Result: The reviewer determined that the requested services are medically necessary and reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be 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.