Plastic Surgery Consultation denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for a third opinion consultation with a plastic surgeon. The Health Plan has denied this request indicating that the requested services are not medically necessary for evaluation of the enrollee’s medical condition. Findings: There is support in the documentation provided for the medical necessity of the requested services in this clinical setting. The initial consultation with a plastic surgeon proposed a different treatment plan from the second plastic surgeon. The first surgeon suggested a staged approach with mastopexy followed by augmentation mammaplasty. The second plastic surgeon recommended an apparent single stage procedure, as well as other surgical options.

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for a referral to a plastic surgeon for a consultation. According to one group of authors, “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. This favors the formation of chronic open wounds with fungal and bacterial infections. These are usually found in the area of the inner thighs, armpits, and the fold of the abdominal wall. The continuous rubbing taking place in these areas can lead to real sores and pain and can be responsible for the use of pain medication.” This patient has requested a consultation with a plastic surgeon. A consultation would allow the patient to obtain appropriate medical information and advice.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage enrollee has requested authorization and coverage for consultation with a plastic surgeon. Findings: The physician reviewer found that the submitted documentation does not support the medical necessity of the requested consultation for plastic surgery. According to the records, the patient has generalized skin laxity consistent with the history of massive weight loss. Individuals who undergo massive weight loss will experience some skin laxity. In the absence of clear and compelling documentation of specific signs and symptoms that are clearly related to the excess skin or are health threatening, or cause significant functional disability and have failed to improve despite reasonable attempts at conservative therapy, the requested procedures would not be medically necessary.

The patient is a 24-year-old male with a reported weight loss of over 100 pounds “4 years ago.” There is no reference to what his weight was four years ago, but he weighed 227 pounds at age 14 and now weighs 155 pounds. The patient complained of a discharge from the umbilicus with a foul odor and itching. His primary care provider (PCP) indicated the umbilicus was infected and prescribed an unspecified “cream for belly button.” The cream was presumably a topical antibiotic. The patient was referred to a general surgeon who noted an “over 80 pound” weight loss and recommended a plastic surgery consultation. The patient’s PCP requested authorization for a plastic surgery referral, which was denied by the Health Plan for lack of medical necessity.Two 5x7 photos are enclosed which do not demonstrate a pannus resting below the symphysis pubis or a chronically infected umbilicus.

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 Plastic Surgery Consultation, then check the rights and deadlines that apply to your plan.