Liposuction 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 bilateral mastectomy and liposuction procedure (CPT 19300 and 15877). Arya and colleagues state that, “True gynecomastia refers to enlarged glandular tissue rather than deposition of fat tissue. Enlargement of breast due to deposition of fat in the breast area is known as pseudogynecomastia.” The authors noted that, “The aims of surgery are: (a) To eliminate painful breast tissue. (b) To restore the patient’s chest to acceptable cosmetic shape. The most commonly used technique is subcutaneous mastectomy that involves direct resection of the glandular tissue using a peri-areolar or trans-areolar approach, with or without liposuction.” Per the American Society of Plastic Surgeons (ASPS), the requested bilateral mastectomy and liposuction procedure are not medically necessary.

Findings: The physician reviewer found that The patient has requested authorization and coverage for liposuction surgery. Warren Peled and Kappos state, “Lipedema is an uncommon disorder characterized by localized adiposity of the lower extremities, often occurring in females with a family history of the condition. The adiposity extends from hips to ankles and is typically unresponsive to weight loss. In addition to the aesthetic deformity, women also describe pain in the lower extremities, particularly with pressure, as well as easy bruising. Although the condition is well described, it is relatively rare and often misdiagnosed.” The authors further note, “Distinguishing lipedema from other conditions causing fatty excess in the lower extremities can be difficult.

Where the denial was upheld

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient requested authorization and coverage for lipedema and panniculectomy surgeries.The authors of a study stated that lipedema is an uncommon disorder characterized by localized adiposity of the lower extremities, often occurring in females with a family history of the condition. The adiposity extends from hips to ankles and is typically unresponsive to weight loss. In addition to the aesthetic deformity, patients also describe pain in the lower extremities, particularly with pressure, as well as easy bruising. One of the major distinguishing features of lipedema is the sparing of the feet, which can create a distinct step-off at the ankle.

Nature of Statutory Criteria/Case Summary: The patient requested authorization and coverage for Stage 1 lipedema surgical procedure (bilateral lower extremity, posterior trunk, buttock shelf and/or bilateral upper arms and Stage 2 lipedema surgical procedure (bilateral lower extremity, anterior, trunk, abdomen and/or excision of excessive skin and tissue.Medical literature indicates that lipedema is an extremely common disease believed to affect 11% to 39% of the female Caucasian population worldwide and 16 million females in the U.S. Studies noted that lipedema is a disorder characterized by localized adiposity of the lower extremities, often occurring in females with a family history of the condition. The adiposity extends from hips to ankles and is typically unresponsive to weight loss.

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