Excess Skin Removal denials in California external review

What the reviewers wrote

Where the denial was overturned

A 54-year-old female has requested abdominal wall reconstruction/panniculectomy, hernia repair (CPT 49560), breast tissue reconstruction/mastopexy (CPT 19319), and excessive skin removal/whole body lift (CPT 15831 for treatment of her medical condition status post gastric bypass with weight loss. Findings: The physician reviewer found that the excess abdominal tissue of the lower abdomen and ptotic breast tissue should be considered abnormal as a result of obesity and subsequent weight loss. This finding is consistent with the photographs and medical documentation as obesity can be considered a disease. Obesity correction is known to create significant functional deficits as documented in the references. The patient does complain of difficulties with her overlapping tissue of the breasts and abdomen.

A 40-year-old female enrollee has requested excision, excessive skin and subcutaneous tissue of the: thigh (CPT 15832); buttock (15835); arm (15836); other area (15839); and mastopexy (19316) for treatment of her excess skin. Findings: The physician reviewer found that the overlap of the breasts, as seen in the photographs and documented clinically, is considered an abnormal enlargement of this area. Obesity can be considered a disease and would thus have led to the abnormal overlapping of the skin that worsens with correction of the underlying disease. The requested procedure of the breasts (mastopexy) is being performed to improve function and would create a normal appearance to the extent possible. The patient is documented by more than one provider to have functional problems as a result of the overlapping skin in this area.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for abdominoplasty provided, brachioplasty, fat injection to bilateral breasts, neck lift, and excision of gynecomastia for treatment of the enrollee, who is status post gastric bypass surgery. Findings: The physician reviewer found that regarding the abdominoplasty performed, there is insufficient documentation of failed typical dermatologic measures. The photographs only document mild lower abdominal excess. The excess skin following significant weight loss is an abnormal occurrence. Additionally, this was caused by the disease of obesity. However, the abdominoplasty was not performed to either improve function or create a normal appearance to the extent possible. The patient had a relatively normal appearance of the abdomen, and conservative treatment of the condition was not well-described.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for excess thigh skin removal. The records do not establish the medical necessity for the proposed thigh dermatolipectomies. The thigh dermatolipectomies are proposed as a treatment for recurrent infections, but the records do not include objective evidence of recurrent infections in the patient’s history. Specifically, the medical records do not include office notes, dermatology consultations, and prescription records for treatment of infections in the thigh folds. Moreover, photographs documenting cellulitis, ulcerations, or rashes were not submitted for review. The letter from the patient’s provider describes a history of thigh infections but problems with thigh infections are not mentioned in any of the multiple provider’s clinical notes provided for review.

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