Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for abdominoplasty, breast reconstruction, complex trunk repair, bilateral brachioplasty and liposuction. According to the American Society of Plastic Surgeons (ASPS) state, Abdominoplasty, typically performed for cosmetic purposes, involves the removal of excess skin and fat from the pubis to the umbilicus or above, and may include fascial plication of the rectus muscle diastasis and a neoumbilicoplastyA cosmetic abdominoplasty is sometimes performed at the time of a functional panniculectomy or delayed pending completion of weight reduction. In this case, the patient reported having undergone a panniculectomy, and did not believe that she underwent liposuction. However, the records support an abdominoplasty and liposuction as having been performed. While the patient reports dog ears at each end of the transverse abdominal incision, this concern is cosmetic rather than regarding functional disability. Therefore, abdominoplasty,  liposuction, and complex trunk repair are not medically necessary for the treatment of this patient.The records note that the patient underwent bilateral breast reduction with removal of 1252 grams from the right breast and 1725 grams from the left breast. The patient reported that her breasts were flat, her nipples were of unequal height, and that her areolae margins were jagged. A physical examination reported that the shape and contour of the patients breasts are typical for breast reduction, and that the level of her nipples are within 1.5 cm of each other. Therefore, breast reconstruction is not medically necessary for the treatment of this patient. The ASPS notes that only in rare circumstances will buttock, thigh, or arm lifts be needed to treat functional abnormalities and that typically, these procedures are performed to improve appearance and are therefore cosmetic in nature. Despite being requested, the submitted records did not include medical or photographic evidence of significantly lax arm skin or of rashes underneath the arms. While the patient reported rashes, the records did not include appropriate medical treatment of a rash or of failure of appropriate medical treatment of a rash. Therefore, bilateral brachioplasty 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. In this case, the requested abdominoplasty, liposuction, complex trunk repair, and breast reconstruction are not performed to improve function. The patients appearance appears to be within the wide range of normal. The requested bilateral brachioplasty is not to improve function, and there is no documentation that the appearance of the arms is not a reflection of the normal structural changes that are accommodative responses to gain or loss of body mass. Therefore, abdominoplasty, breast reconstruction, complex trunk repair, bilateral brachioplasty and liposuction are not reconstructive in nature for the treatment of this patient.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition and are not reconstructive in nature. 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.