Revision Procedures denials: what the review data shows

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: The patient has requested authorization and coverage for endoscopic revision of gastrojejunal anastomosis (CPT code 43999) and anesthesia (CPT code 00731). Thompson and colleagues studied the safety and efficacy of transoral outlet reduction for the treatment of weight regain in Roux-en-Y gastric bypass patients. Weight loss or stabilization was achieved in 96% of patients six months after outlet reduction. Researchers noted, “When implemented as part of a multidisciplinary intervention, transoral outlet reduction using endolumenal suturing is safe, reproducible, and effective approach to manage weight recidivism after Roux-en-Y gastric bypass surgery.” In this case, the patient has coronary artery disease requiring intervention at a young age.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient is a 62-year-old female with a history of intraductal carcinoma in situ of the left breast.Findings: The physician reviewer found that the patient presented for bilateral nipple sparing mastectomies, left axillary sentinel lymph node biopsy, and AlloDerm assisted immediate bilateral breast reconstruction with silicone implants. Later , the records noted that bilateral breast implants were in place, with no signs of infection, hematoma, seroma, or ischemia. Then the records noted that the “patient would like larger implants to be placed.” In an application for independent medical review , the patient reported asymmetry of the breasts and a large space between the breasts.

Findings: The physician reviewer found that The patient has requested authorization and coverage for staged excision of foreign body fat necrosis with antibiotic washout, debridement, and flap reconstruction of the hip area, legs, and gluteus maximus. The records document that this patient underwent buttock augmentation with injectable silicone or other substance at a non-medical facility after a previous gluteal augmentation with fat injection. The injected material is settling and causing deformity as well as tender and painful nodules. The patient presents with complaints of tender nodules and product migration to hip and groin folds with increased pain in buttocks, hips, and groin. The patient complains of numbness and tingling down legs, and intermittently feels unable to walk or feel the legs.

These are outcomes from California’s external review program — an independent physician panel that binds the insurer. Every state has an equivalent process, and internal appeals succeed even more often. Cite the outcome record for Revision Procedureswhen you appeal: reviewers routinely find that denials like yours didn’t hold up.