Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for surgeries. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees excess skin and were not reconstructive in nature.Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested panniculectomy. The panniculus did not hang below the level of the pubis.  There was no report of a recurrent rash underneath the abdominal panniculus. There was no report of appropriate medical treatment of a rash or of failure of appropriate medical treatment of a rash. Based on the submitted records, the patient did not have a functional problem with a rash that was demonstrated to be resistant to appropriate medical treatment. Thus, the panniculectomy was not medically necessary. Additionally, the abdominal pannus was not an abnormal structure of the body. With regards to the pannus, the records do not document an abnormal structure of the body caused a congenital defect, a developmental abnormality, trauma, infection, tumors or disease. The appearance of the patient was normal and consistent with the gain and loss of weight. Thus, the panniculectomy was not reconstructive in nature.With regards to the abdominoplasty, the records fail to demonstrate the medical necessity of the services at issue. The American Society of Plastic Surgeons notes that the CPT code applied describes a cosmetic procedure.  The records did not document a functional problem which would support the medical necessity of the services at issue. Additionally, the patients excess skin was not an abnormal structure of the body. Lax abdominal tissue is not a result of a congenital defect, a developmental abnormality, trauma, infection, tumors or disease. Thus, abdominoplasty was not reconstructive in nature and was not medically necessary.With regards to the hip lift and buttocks lift, the submitted records fail to demonstrate the medical necessity of the services at issue. The photographs show fatty fullness without skin excess in the hip area and buttocks deflation without significant skin redundancy. There is no report of a rash in the area or of failure of medical treatment of a rash in the hip or buttocks regions. As noted above, the patients excess skin was not an abnormal structure of the body. Excess and loose tissue in the hip and buttocks areas is not a result of a congenital defect, a developmental abnormality, trauma, infection, tumors or disease. Thus, the hip lift and buttocks lift were not medically necessary and were not reconstructive in nature.With regards to the mastopexy with breast augmentation, the medical necessity of the services at issue has not been established. This patients weight reduction and hormone treatment resulted in ptotic female breasts with a smaller cup size. There is no report of a rash under the breasts or of failure of medical treatment of a rash underneath the breasts. Based on the medical information received for review, mastopexy was not medically necessary for functional correction of ptotic breast tissue. An augmentation mammoplasty would result in no functional correction of physical problems in the breast area. Breast augmentation is not medically necessary for any functional problems following weight loss. The patients condition was not an abnormal structure of the body. Breast ptosis and loss of breast volume is not a result of a congenital defect, a developmental abnormality, trauma, infection, tumors or disease. In sum, the mastopexy with breast augmentation were not reconstructive in nature and were not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services were not medically necessary 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.