Reconstructive & Plastic Surgery denials in California external review

What the reviewers wrote

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 suction assisted lipectomy of the bilateral arms and bilateral legs with associated hospitalization.Researchers report that lipedema is believed to affect 11% to 39% of the female Caucasian population worldwide, and that as many as 16 million women in the United States may be affected with the disorder. Researchers 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.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for breast implant removal surgery (CPT 19371-RT, 19371-LT, 19328-RT, and 19328-LT) performed by Dr. Lisa Cassileth on 11/02/20.At issue is whether breast implant removal surgery (CPT 19371-RT, 19371-LT, 19328-RT, and 19328-LT) performed by Dr. Lisa Cassileth on 11/02/20 was medically necessary for treatment of the patient’s medical condition. Does the condition constitute an abnormal structure of the body? If so, is the abnormal structure of the body caused by any of the following: congenital effects, developmental abnormalities, trauma, infection, tumors, or disease? If so, is the requested surgery performed to do either of the following: improve function or create a normal appearance to the extent possible?

Where the denial was upheld

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for abdominoplasty, panniculectomy, liposuction of the thighs, liposuction of the abdomen, lipectomy, and/or breast lift. As noted by expert studies in the field, abdominoplasty, panniculectomy, and abdominal lipectomy involve surgical removal of excessive fat and skin from the abdomen. Per the studies, when surgery is performed to alleviate such complicating factors as the inability to walk normally, chronic pain, ulceration created by the abdominal skin fold, or intertrigo dermatitis, and the symptoms have been present for at least three months and are refractory to usual standard medical therapy, such surgery may be considered reconstructive.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for surgical procedures. According to medical study guidelines, 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. Similarly, in the case of skin laxity requiring resection with a panniculectomy, the authors reported that “A panniculectomy must meet specific criteria to be medically necessary. The pannus must hang below the level of the pubis and be confirmed with photography. Patients must fail medical treatment of intertrigo for three months. Medical treatment includes good hygiene, topical antifungals, corticosteroids, and antibiotics.

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 reconstructive & plastic surgery, then check the rights and deadlines that apply to your plan.