Lipoma: when insurers say no, reviewers often say yes

Where the denial was overturned

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for lipoma removal. According to the National Cancer Institute (NCI), a tumor is an abnormal mass of tissue that forms when cells grow and divide more than normal or do not die when they should. Tumors may be benign or malignant. A lipoma is considered a benign tumor. The records indicate that this patient’s lipoma is causing back pain and discomfort. The chart notes indicate that the mass is consistent with a lipoma as noted on an ultrasound. Based on the reports that the patient’s lipoma is causing pain and discomfort, the requested surgery is being performed to improve function.

Nature of Statutory Criteria/Case Summary: an enrollee has requested authorization and coverage for removal of a fatty lump in the neck. Findings: The physician reviewer found that Tte medical records document a mass of the right neck which is consistent with a probable lipoma. Although this may be a benign condition, there are several indications for removal. The mass is noted to be increasing in size, and the size is relatively large at 2 x 4 x 3 cm, especially considering the anatomic location of the upper neck above the level of the platysma. Per the medical evidence, as the mass is both large and enlarging, surgical resection to confirm the diagnosis is medically reasonable. Additionally, the requested services are reconstructive in nature. A lipoma or fatty mass is not a normal structure of the body. This abnormal structure can be classified as a tumor.

Where the denial was upheld

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for computed tomography (CT) scan of the right shoulder. Researchers explain that some deep-seated lipomas are technically challenging to surgically excise from a dermatologist's perspective. A CT scan may be a necessary option for pre-operative planning of deep lipomas. In this clinical setting, if an initial ultrasound was concerning for deep lipoma, CT or magnetic resonance imaging (MRI) may have been indicated to establish the deep lipoma and the relationship to the neurovascular bundle. However, given that confirmation of the diagnosis and basic information of the location of the mass in relation to the skin fascia and/or musculature could have been determined by an ultrasound, the service at issue was not medically indicated.

A 61-year-old male enrollee has requested for liposuction excision for treatment of his lipoma. Findings: The physician reviewer found that the medical necessity for liposuction excision of the lipoma is not established. The records do not document a concern over malignancy or any functional problems related to the lipoma. The patient indicates in his appeal letter that the lipoma was painful, but the records do not include any preoperative physician documentation indicating the lipoma was symptomatic. Although liposuction is an effective method for removal of lipomas, the medical records do not document any health-related problems secondary to this lipoma.

These outcomes come from California’s external review program — an independent physician panel whose decision binds the insurer. Every state has an equivalent, and internal appeals succeed even more often. If your care for lipoma was denied, the published record says the denial is worth fighting.