Diagnosis: Orthopedic/Musculoskeletal.
Treatment: Surgical Services.
The insurer denied Abdominoplasty Revision and Excision, excessive skin, and subcutaneous tissue (includes lipectomy); buttock.
The denial is upheld.

The patient is a female with a long history of sciatica treated by medications, physical therapy, chiropractor manipulation, acupuncture, and injections (epidural and trigger point). She underwent bariatric surgery and subsequently lost 80 pounds, and then underwent abdominoplasty. She underwent cosmetic abdominal liposuction with fat transfer to the buttocks complicated by infection and toxic shock necessitating surgical incision and drainage and prolonged hospital stay with intravenous (IV) antibiotics. This exacerbated her sciatica and a spinal column stimulator trial failed to provide relief. She is unable to sit properly or comfortably which leads to uneven weight distribution exacerbating the pain and she apparently feels further plastic surgery to remove skin and tighten abdominal muscles will resolve this. Her plastic surgeon is apparently recommending a partial or total belt lipectomy extension of a prior abdominoplasty. Coverage was denied by the health plan because the surgery was considered cosmetic.
The subject under review is whether the proposed surgery is medically necessary.

The health plan's determination is upheld.

The requested abdominoplasty revision and excision, excessive skin, and subcutaneous tissue (includes lipectomy); buttock is not medically necessary for this patient.
Per Milliman Care Guidelines (MCG) Health Ambulatory Care 25th Edition Abdominoplasty ACG: A-0497 (AC)
Abdominoplasty may be indicated when ALL of the following are present:
1) Abdominal wall laxity or skin excess interferes with activities of daily living. [NOT MET]
2) Patient has complications from a panniculus (i.e., chronic, or recurrent intertrigo,
other skin infection, ulceration, or skin irritation that has been persistent despite
nonsurgical treatment). [NOT MET]
3) Patient's weight has reached stable plateau, and 1 or more of the following:
a) Adherence to multidisciplinary nonsurgical program of weight maintenance
b) One year or more has elapsed following bariatric surgery. [MET by bariatric surgery in 2012]
The criteria are not met, and revision of the prior abdominoplasty is not medically necessary.
Given the absence of rashes or infection in the front, removal of excess mons and abdominal skin would be primarily for the improvement of appearance after an inadequate cosmetic abdominoplasty result. The surgery is cosmetic, and will not resolve her lumbar radiculopathy pain, and will not resolve her left buttock contour irregularity. Therefore, the requested health service/treatment of Abdominoplasty Revision and Excision, excessive skin, and subcutaneous tissue (includes lipectomy); buttock is cosmetic and not medically necessary for this patient.