Excess Skin denials in California external review

What the reviewers wrote

Where the denial was overturned

A 36-year-old female enrollee has requested for removal of excess skin from the buttocks, hips, and arms for treatment of her excess skin. Findings: The physician reviewer found that abdominoplasty is a procedure that involves placement of transverse suprapubic/lower abdominal and periumbilical incisions. The abdominal skin is then tightened by excising the caudal portion of abdominal skin and creating a new umbilical opening higher up on the skin that has now been stretched downward. Panniculectomy is a lesser procedure that only involves removal of the lower abdominal skin without the muscle tightening or the supraumbilical skin tightening via periumbilical and lower abdominal incisions. A buttock lift is an abdominoplasty or panniculectomy that is extended circumferentially around the back of the body.

A 19-year-old male enrollee has requested reimbursement for services of an assistant surgeon during a bilateral brachioplasty and assistant surgeon services for abdominoplasty treatment of the enrollee’s excess skin. Findings: The physician reviewer found that the submitted documentation establishes the medical necessity of the services at issue. Surgeons call upon assistants to utilize problem-solving skills that are only developed through medical and surgical training. The primary surgeon’s decision about who is most appropriate to serve as an assistant at surgery may be based on factors such as the nature of a specific operation, the unique medical circumstances of an individual patient, the availability of appropriately trained physicians or non-physician staff, or ready access to other appropriately trained specialists.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for upper arm and breast lift procedures for treatment of the enrollee who has a history of excess skin due to weight loss. Findings: The physician reviewer found that the requested services are not medically necessary and are not reconstructive in nature. Overall, there has been insufficient documentation to support that there is a functional deficit related to this patient’s excess soft tissue. As such, the requested services are not medically necessary. Based on the submitted records, the patient has generalized skin laxity consistent with her history of massive weight loss. Correction of skin laxity following massive weight loss is not medically necessary in the absence of clear and compelling documentation of specific signs and symptoms.

A 40-year-old female enrollee requested a panniculectomy (CPT 15830) for medical treatment of her excessive skin. Findings: The physician reviewer found that overall, there is inadequate documentation to support that the patient has a functional deficit that would benefit from panniculectomy. The provider’s notes do not include sufficient detail of the abdominal overhang and the dermatologic treatment that has been attempted. The medication history does not list any topical medications that may be used to treat rashes and/or fungal infections. The photographs depict only a mild overhang and the area underneath the overlap is not provided for evaluation. The examination notes do not include any evidence of intertrigo, increased moisture, malodor and/or chronic changes to support that a functional deficit exists.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving excess skin, then check the rights and deadlines that apply to your plan.