Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient is a female who requests authorization and coverage for panniculectomy and mastopexy. The Health Plan has denied the request and reported the requested services are not medically necessary and not reconstructive in nature for treatment of the patients medical condition. The submitted documentation fails to demonstrate the medical necessity of the requested abdominal panniculectomy. Based on the patients photographs, the panniculus does not hang below the level of the pubis. Although the patient reported that she has had a recurrent rash underneath her abdominal pannus, the records do not document failure of appropriate medical treatment of the rash. The clinical notes do not document a functional problem with the rash which has been demonstrated to be resistant to appropriate medical treatment. Therefore, the requested abdominal panniculectomy is not medically necessary. With regards to the requested abdominal panniculectomy, the patients condition does not constitute an abnormal structure of the body. An abdominal pannus is not a result of a congenital defect, a developmental abnormality, trauma, infection, tumors or disease. It is a normal structural change that is an accommodative response to gain or loss of body mass. The requested abdominal panniculectomy is not likely to improve function or create a normal appearance to the extent possible. The appearance of the patient is normal and consistent with the gain and loss of weight. Therefore, the requested abdominal panniculectomy is not reconstructive in nature. The clinical notes fail to demonstrate the medical necessity of the requested bilateral mastopexy. This patient reported a recurrent rash underneath her breasts, but there were no photographs documenting the area under the breasts or a rash under the breasts. There is no report of appropriate medical treatment of a rash under the breasts or of failure of appropriate medical treatment of a rash under the breasts. In this case, the records do not document a functional problem with a rash under her breasts that has been demonstrated to be resistant to appropriate medical treatment. In sum, the requested bilateral mastopexy is not medically necessary for the treatment of this patient. With regards to the requested bilateral mastopexy, the patients condition does not constitute an abnormal structure of the body. Breast ptosis is not a result of a congenital defect, a developmental abnormality, trauma, infection, tumors or disease. It is a normal structural change that is an accommodative response to gain or loss of body mass and to physical aging. The requested bilateral mastopexy is not likely to improve function or create a normal appearance to the extent possible. The appearance of the patient is normal and consistent with the gain and loss of weight. Thus, the requested bilateral mastopexy is not reconstructive in nature.Final Result: The reviewer determined that the requested services are 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.