Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral lymph sparing lipectomy of the upper extremities, lower extremities and/or the trunk, and excision of excessive skin/subcutaneous tissue of the thighs, legs, arms and/or other areas. Researchers noted that lipedema is a disorder characterized by localized adiposity of the lower extremities, often occurring in females with a family history of the condition. Researchers reported that a diagnosis of lipedema is established on the basis of medical history and clinical findings. Characteristically, there is a localized, symmetrical increase in subcutaneous adipose tissue in arms and legs that is in marked disproportion to the trunk. Other findings include edema, easy bruising, and increased tenderness. The authors noted that, Lipedema is a chronic, progressive disorder marked by the individual variability and unpredictability of its clinical course. The records provided for review document that this patient has severe obesity with a BMI over 40 kg/m2. She underwent bariatric surgery, and she was able to lose weight down to a BMI of 37.8 kg/m2. She has subsequently gained weight and she reports an inability to lose weight. However, there is no report of persistence of disproportionate fat despite significant weight loss. In addition, the photographs of the upper extremities do not show significant enlargement given the patients body habitus. Clinically significant cuffing is not present and lower extremity bruising is not specific to support a diagnosis of lipedema. For these reasons, the requested bilateral lymph sparing lipectomy of the upper extremities, lower extremities and/or the trunk, and excision of excessive skin/subcutaneous tissue of the thighs, legs, arms and/or other areas is not 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. A diagnosis of lipedema is not confirmed by the medical information received for review. The patient presents with severe exogenous obesity, with a BMI greater than 40 kg/m2. Exogenous obesity is not an abnormal structure of the body caused by a result of a congenital defect, a developmental abnormality, trauma, infection, tumor, or disease. The patients obesity is a normal structural change that is an accommodative response to the gain or loss of body mass. The appearance of the patient is normal and consistent with the gain and loss of weight. Furthermore, the records do not document that the requested surgical interventions will improve a functional impairment or provide a more than minimal improvement in the patients appearance. All told, the requested bilateral lymph sparing lipectomy of the upper extremities, lower extremities and/or the trunk, and excision of excessive skin/subcutaneous tissue of the thighs, legs, arms and/or other areas is not reconstructive in nature for treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary and not reconstructive in nature 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.