Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for (1) surgery to remove excessive skin from bilateral arms  and (2) surgery to remove excessive skin from bilateral thighs. Findings:  The physician reviewer found that The submitted documentation supports the medical necessity of a portion of the requested services. According to the American Society of Plastic Surgeons, 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. Ngaage and colleagues note that in determining the medical necessity of brachioplasty and thighplasty following bariatric surgery, the most common criterion requested by insurance companies was evidence of functional impairment or interference with activities of daily living, along with documentation of persistent or recurring skin rash, ulceration, necrosis, dermatitis, candidiasis, or intertrigo, refractory to medical therapy frequently appeared in insurance policies. In this case, the patients weight decreased from 320 pounds to 187 pounds following bariatric surgery. An examination showed intractable intertrigo of the bilateral arms with blistering rashes that have persisted despite treatment with nystatin cream. The patients large arm pannus bilaterally causes myofascial related shoulder pain preventing her from engaging in activities of daily living. In this clinical setting, (1) surgery to remove excessive skin from bilateral arms is medically necessary to treat the enrollees medical condition. While the patient reports back, shoulder, and leg pain, along with a limp, due to the weight of the excess skin, the records do not document an association of the patients pain with tissue laxity in the thigh area. There is no history of rashes on the thigh that are unresponsive to medical treatment. Photographs show residual fullness and tissue laxity in the medial thigh region without evidence of a hanging pannus. There is no documentation of functional impairment or interference with activities of daily living due to the residual fat and skin in the thigh region. In this clinical setting, (2) surgery to remove excessive skin from bilateral thighs is not medically necessary for the 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; (2) to create a normal appearance, to the extent possible. The patients markedly excess arm skin is an abnormal structure of the body caused by a developmental abnormality. The purpose of the skin excision brachioplasty is to relieve pain and intractable rash formation and to improve function. Thus, (1) surgery to remove excessive skin from bilateral arms is not reconstructive of nature. While the patient has some residual skin and fat in the medial thigh area, this is a normal structural change that is an accommodative response to gain or loss of body mass and is not an abnormal structure of the body. The appearance of the patient is normal and consistent with the gain and loss of weight. Thus, (2) surgery to remove excessive skin from bilateral thighs  is reconstructive in nature.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.