Lipodystrophy denials in California external review

What the reviewers wrote

Where the denial was overturned

A 55-year-old female has requested a panniculectomy for treatment of her lipodystrophy. Findings: The physician reviewer found that based on review of the available records, the patient presents with a severely enlarged overhanging pannus, which is an abnormal state of the abdomen. In addition, the patient is being treated for obesity which can be classified as a disease. The records indicate the requested surgery is being performed to both improve function and create a normal appearance to the extent possible. The patient is noted to have chronic back pain treated with multiple analgesics. Based on the photographs, one would expect the patient to have a significant functional deficit related to a severely enlarged pannus. She is noted to have chronic back pain as well as limitations related to further weight loss and exercise.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for liposuction of the trunk (CPT 15877) and neck (CPT 15876). This patient presents with evidence of severe lipodystrophy of the neck and back as a likely complication of her treatment for congenital HIV. Liposuction is supported in the medical literature for use to treat deformities in a reconstructive fashion, as is the case for this patient. Colleagues noted that the standard treatment for HIV is a “combination of protease inhibitors and reverse transcriptase inhibitors.

Where the denial was upheld

A 57-year-old male enrollee has requested Egrifta for treatment of his human immunodeficiency virus (HIV) and lipodystrophy. Findings: The physician reviewer found that lipodystrophy is an abnormal accumulation of fat. The abnormal collection may be caused by the treatment of HIV, which is an infection. As stated in the press release from the U.S. Food and Drug Administration (FDA), Egrifta is noted to decrease abdominal fat and some patients reported improvements in their self-image. Falutz and colleagues found that Egrifta “might be useful for the treatment of HIV-infected patients who have an increase in abdominal girth and dyslipidemia in the context of receiving antiretroviral therapy.” Given the FDA approval, Egrifta may be a strategy to create a normal appearance to the extent possible.

A male enrollee requested Serostim 4 mg daily for medical treatment of his lipodystrophy secondary to human immunodeficiency virus (HIV) medications. Findings: The physician reviewer found that as noted by the U.S. Food and Drug Administration (FDA), Serostim is “indicated for the treatment of HIV patients with wasting or cachexia to increase lean body mass and body weight, and improve physical endurance”. The records indicate that due to documented and stated findings of lipodystrophy previously, this patient began taking Serostim. At the time, he was noted to have significant lipoaccumulation of the abdomen and muscle wasting of the face, arms, legs and buttocks. Based on the documentation, the patient appears to have improved from this status. He reports that his waist size is down significantly and that he has regained appropriate muscle mass.

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 lipodystrophy, then check the rights and deadlines that apply to your plan.