Brachioplasty denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for (1) surgery to remove excessive skin from bilateral arms and (2) surgery to remove excessive skin from bilateral thighs. Findings: The physician reviewer found that The submitted documentation supports the medical necessity of a portion of the requested services. According to the American Society of Plastic Surgeons, when surgery to remove extensive skin redundancy and fat folds is performed solely to enhance a patient’s appearance in the absence of any signs or symptoms of functional abnormalities, the procedure should be considered cosmetic in nature.

Nature of Statutory Criteria/Case Summary: An enrollee has requested bilateral arm lift (brachioplasty), breast lift (mastopexy), thigh lift (thighplasty), and panniculectomy for treatment of the enrollee’s weight loss status post bariatric surgery. Findings: The physician reviewer found that the records indicate that this patient experienced significant weight loss following bariatric surgery. Based on the documentation provided, a clear functional deficit has not been defined related to her excess soft tissue and skin overlap of the arms, breasts, abdominal pannus and thighs. Photographs show evidence of mild soft tissue excess of the arms, Grade II/III ptosis of the breasts, an overhanging lower abdominal pannus and severe soft tissue excess of the thighs.

Where the denial was upheld

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for brachioplasty, belt lipectomy, and/or thighplasty. A study reported that in post-massive weight loss patients “Skin irritation is the most frequently expressed complaint. Heat accumulates due to skin surfaces lying on top of each other, and in the absence of air circulation, moist chamber forms, disrupting the natural skin barrier.” The authors observed that this favors the formation of chronic open wounds with fungal and bacterial infections in several areas including the inner thighs, armpits, and the fold of the abdominal wall. The authors noted that continuous rubbing in these areas can lead to sores and pain, requiring the use of pain medication.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for a lower body lift (skin excision buttock/thighs), upper body lift (skin excision breast/chest), and arm lift (brachioplasty). A lower body lift involves the removal of excess skin and fat from the inner thighs and buttocks to reshape and improve the contour, providing both aesthetic and functional benefits. In this case, there is no report or documentation of functional impairment in walking, sulcus dermatitis, intertrigo, or poor groin hygiene. In addition, there is no report or documentation of severe skin irritation that is unresponsive to medical treatment. Based on the records, the requested lower body lift (skin excision buttocks/thighs) is not medically necessary for the treatment of the patient.

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