Reconstructive and plastic surgery: 45% of denials overturned

Year by year

By treatment

Treatments with at least 20 decisions, most decisions first. Rates on fewer than 20 decisions aren’t shown.

Recent decisions

The most recent decisions in the data, half overturned and half upheld. Each shows the reviewer’s published findings.

1. Upheld 2026 · Medical necessity · age 41–50 Excess skin removal · Skin The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for panniculectomy. Excess skin associated with significant weight loss may contribute to impaired hygiene, intertrigo, discomfort…

   The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for panniculectomy. Excess skin associated with significant weight loss may contribute to impaired hygiene, intertrigo, discomfort, and functional limitations. Current expert guidance indicates that panniculectomy may be considered in select patients with documented panniculitis or chronic skin complications refractory to medical management.In this case, the patient’s photographs demonstrate that the panniculus does not extend below the pubic symphysis or genitalia. Additionally, the records do not adequately document failure of prescription medical therapy for intertrigo or ulceration. Abdominoplasty is considered a cosmetic procedure involving removal of excess skin and fat and may include fascial plication or neoumbilicoplasty.The California reconstructive surgery statute defines reconstructive surgery as surgery performed to correct or repair abnormal body structures caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease in order to improve function or create a normal appearance to the extent possible. In this case, the requested panniculectomy and abdominoplasty are not reconstructive in nature because the procedures are not intended to correct an abnormal structure caused by one of these qualifying conditions and would not be expected to provide more than minimal functional improvement.Given these findings, the requested panniculectomy is not medically necessary and is not reconstructive in nature for the treatment of this patient. Final Result: The reviewer determined that the requested procedures are not medically necessary for the treatment of the patient’s medical condition. Therefore, the Health Plan’s denial should be upheld. Credentials/Qualifications: The reviewer is board-certified in plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the patient’s medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN26-46709

2. Upheld 2026 · Medical necessity · age 31–40 Mastopexy · Kidney and urinary The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for bilateral mastopexy surgery with acellular dermal matrix implant, and graft with vascular flow test. The classification of…

   The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for bilateral mastopexy surgery with acellular dermal matrix implant, and graft with vascular flow test. The classification of breast ptosis is predicated on the relationship of the nipple to the inframammary fold. In Grade 2 ptosis, the nipple is 1 to 3 cm below the inframammary fold, but is still located above the lowest point of the breast. Mastopexy is a cosmetic procedure that utilizes reconstructive principles from other breast procedures. The goals of mastopexy are to reshape the breast, redistribute volume, and reposition the nipple-areola complex. Breast reduction operations strive for these same aesthetic goals while also reducing the size and weight of the breasts for functional purposes. According to researchers, free nipple grafting may achieve equal or better aesthetic and functional outcomes compared to traditional reduction mammaplasty techniques. In this case, the patient has lost significant weight and developed severely deflated breasts with Grade 2 ptosis. Mastopexy is a cosmetic surgery and not a correction of a physical functional complaint. Based on the medical records, the requested bilateral mastopexy surgery is not supported as medically necessary for the treatment of this patient. Acellular dermal matrix implant and graft with vascular flow test would be a part of the requested bilateral mastopexy. Accordingly, the requested acellular dermal matrix implant and graft with vascular flow are also not supported as medically necessary for the treatment of the patient. All told, the requested bilateral mastopexy surgery with acellular dermal matrix implant, and graft with vascular flow test is not medically necessary to protect life, prevent significant illness or significant disability, or alleviate severe pain through the diagnosis or treatment of disease, illness, or injury in the patient. In addition, the requested bilateral mastopexy surgery with acellular dermal matrix implant, and graft with vascular flow test is not medically necessary for the patient to achieve age-appropriate growth and development, and attain, maintain, or regain functional capacity.The California reconstructive surgery statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function; or (2) to create a normal appearance, to the extent possible. In this case, the patient presents with sagging breasts (breast ptosis) after massive weight loss, which is not an abnormal structure of the body. The patient’s condition is a normal structure of the body evidencing changes due to gain and loss of body mass. The patient’s condition is not caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease As such, the California reconstructive surgery statute does not apply to the patient.Therefore, the requested bilateral mastopexy surgery with acellular dermal matrix implant, and graft with vascular flow test is not medically necessary and is not reconstructive in nature for the treatment of this patient. Final Result: The reviewer determined that the requested service is not medically necessary and is not reconstructive in nature for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be upheld. Credentials/Qualifications: The reviewer is board-certified in plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the patient's medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN26-46520

3. Upheld 2026 · Medical necessity · age 41–50 Excess skin removal · Skin The physician reviewer found that a patient has requested authorization and coverage for a panniculectomy.Medical literature generally notes that excess lower‑abdominal skin after significant weight loss can impair hygiene, cause irritation, and contribute to…

   The physician reviewer found that a patient has requested authorization and coverage for a panniculectomy.Medical literature generally notes that excess lower‑abdominal skin after significant weight loss can impair hygiene, cause irritation, and contribute to discomfort, and that panniculectomy may be considered when chronic skinfold issues persist despite medical treatment.On review of the records, this patient has lax abdominal skin after major weight loss. The patient complains of rashes and skin irritation under an abdominal pannus. The patient reported use of powders and prescription creams with continued symptoms. Physical examination reports an abdominal pannus with a 5 cm suprapubic overhang, measuring 4 cm in thickness. However, there is no report of intertrigo underneath the pannus. Clinical color photographs show obesity, diastasis recti, and a lower abdominal pannus that overhangs the pubis. Physical examinations by the patient’s primary care physician and plastic surgeon do not report a rash underneath the abdominal pannus. Overall, the records do not document medical treatment of a rash, failure of medical treatment of a rash, or the presence of a chronic skinfold maceration that has failed to respond to oral or topical treatment for at least three months to support the requested panniculectomy. Therefore, the requested panniculectomy is not medically necessary for the treatment of the patient’s medical condition. The California reconstructive surgery statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function, or (2) to create a normal appearance, to the extent possible. The records document that this patient has lax lower abdominal skin following major weight loss. However, the providers did not chart the presence of a rash under the lax skin or functional issues related to the abdominal pannus. Lax abdominal skin after weight loss is not an abnormal structure of the body. Rather, lax abdominal skin is a normal accommodation of the body to the gain and loss of weight. Lax abdominal skin was not caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease. Furthermore, the requested panniculectomy would not result in more than a minimal improvement in the patient’s appearance. For these reasons, the requested panniculectomy is not reconstructive in nature for the treatment of this patient. All told, the requested panniculectomy is not medically necessary and not reconstructive in nature for the treatment of this patient. Final Result: The reviewer determined that the requested service is not medically necessary and not reconstructive in nature for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be upheld. Credentials/Qualifications: The reviewer is board-certified in plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the patient’s medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN26-46379

4. Upheld 2025 · Medical necessity · age 31–40 Excess skin removal · Skin The physician reviewer found that a patient has requested authorization and coverage for panniculectomy. A panniculus is usually present in post-massive weight loss patients, preventing adequate hygiene, reducing functional capacity and mobility, and…

   The physician reviewer found that a patient has requested authorization and coverage for panniculectomy. A panniculus is usually present in post-massive weight loss patients, preventing adequate hygiene, reducing functional capacity and mobility, and determining significant psychosocial stress. Medical literature generally notes that excess skin folds can trap moisture, increase friction, and predispose individuals to irritation, infection, and discomfort. According to a survey of North American Plastic Surgeons, the most common criteria for panniculectomy include stable weight for several months and chronic skinfold maceration without response to oral or topical treatment for three months. In this case, the patient has reported a protruding pubis area, as well as internal issues with adhesions on the bowels that cause uncontrollable severe constipation, pain, bloating, anal fissures, and blood in stools. The patient’s physical examination revealed a small panniculus with a small amount of overhanging skin. The records do not sufficiently document reports of rash, intertrigo, or skin irritation underneath the pannus. There is no report of medical treatment of a rash or of failure of medical treatment of a rash, and no report of chronic skinfold maceration under the pannus without response to oral or topical treatment for at least three months. Given these findings, the requested panniculectomy is not medically necessary to protect life, prevent significant illness or significant disability, or alleviate severe pain through the diagnosis or treatment of disease, illness, or injury. In addition, the requested panniculectomy is not medically necessary to achieve age-appropriate growth and development, and attain, maintain, or regain functional capacity.The California reconstructive surgery statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function; or (2) to create a normal appearance, to the extent possible. In this case, the patient has a small abdominal panniculus from obesity. The patient’s condition is not an abnormal structure of the body. Rather, it is a normal accommodation to the gain or loss of weight. The patient’s condition is not caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease. As such, the California reconstructive surgery statute does not apply to the patient.Therefore, the requested panniculectomy is not medically necessary and is not reconstructive in nature for the treatment of this patient. Final Result: The reviewer determined that the requested service is not medically necessary and is not reconstructive in nature for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be upheld. Credentials/Qualifications: The reviewer is board-certified in plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the patient's medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN25-46361

5. Overturned 2025 · Medical necessity · age 31–40 Breast reduction · Kidney and urinary The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for bilateral breast reduction surgery. Macromastia constitutes a disease that is diagnosed with symptoms and objective findings…

   The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for bilateral breast reduction surgery. Macromastia constitutes a disease that is diagnosed with symptoms and objective findings. Based on the records, the patient meets the criteria for macromastia, which include large breast size, back pain, neck pain, shoulder grooving, limitation of daily life, and failure to improve with significant weight loss and nonsurgical treatments, such as medication and special garments. Bilateral breast reduction surgery is supported by the medical literature for this patient and will restore function, improve symptoms, and there is significant expectation that it will create a more normal appearance. Notably, the patient even meets the extreme Schnur scale requirements for breast reduction, as the provider plans to remove sufficient weight. All told, the requested bilateral breast reduction surgery is medically necessary for the treatment of this patient.The California reconstructive surgery statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function; or (2) to create a normal appearance, to the extent possible. In this case, the patient presents with macromastia, which constitutes an abnormal structure of the breast organ. Macromastia is an acquired disease confirmed by specific symptoms and physical exam findings. The requested bilateral breast reduction surgery is performed to improve function, and will allow this patient to normalize physical activity and alleviate specific symptoms and physical exam findings, such as back pain, shoulder grooving, and intertrigo. Additionally, breast reduction corrects the deformity characterized by abnormal size of the organ. In this case, enlargement is the abnormality and it is specific to the patient’s body frame. Further, the requested bilateral breast reduction surgery provides more than a minimal improvement in appearance, often providing normalization or significant improvement of the breast. Specifically, the breast size is restored, the nipple areola complex is restored to normal dimensions, the position on the nipple to the breast is normalized, and the position of the breast in the chest is corrected (correction of breast ptosis). As such, the requested bilateral breast reduction surgery is supported as reconstructive in nature for this patient.Therefore, the requested bilateral breast reduction surgery is medically necessary and reconstructive in nature for the treatment of this patient. Final Result: The reviewer determined that the requested service is medically necessary and reconstructive in nature for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be overturned. Credentials/Qualifications: The reviewer is board-certified in plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the patient's medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN25-46294

6. Overturned 2025 · Medical necessity · age 21–30 Other · Mental health The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for a gender-affirming subcutaneous mastectomy. Mastectomy is the most common surgical intervention for transmasculine individuals…

   The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for a gender-affirming subcutaneous mastectomy. Mastectomy is the most common surgical intervention for transmasculine individuals with gender dysphoria and is listed as a potentially medically necessary treatment for gender dysphoria in World Professional Association for Transgender Health (WPATH) Standards of Care Version 8. While mastectomy in obese transgender patients has a higher complication rate, serious complications are uncommon, and body mass index alone should not be a disqualifier for mastectomy. Mastectomy in obese patients is generally still safe and can be an effective treatment for gender dysphoria. Gender-affirming subcutaneous mastectomy for this patient is in accordance with the generally accepted standards of mental health and substance use disorder care, clinically appropriate in terms of type, frequency, extent, site, and duration, and not primarily for the convenience of the patient or provider. All told, the requested gender-affirming subcutaneous mastectomy is medically necessary for the treatment of the patient. The WPATH Standards of Care Version 8 states that “In individuals assigned female at birth, gender-affirming chest surgery or 'top surgery' has been studied in prospective and cross-sectional cohort studies. The efficacy of top surgery has been demonstrated in multiple domains, including a consistent and direct increase in health-related quality of life, a significant decrease in gender dysphoria, and a consistent increase in satisfaction with body and appearance. Additionally, rates of regret remain very low, varying from 0 to 4%. While the effect of top surgery on additional outcome measures such as depression, anxiety, and sexual function also demonstrated a benefit, the studies were of insufficient strength to draw definitive conclusions. Although further investigation is needed to draw more robust conclusions, the evidence demonstrates top surgery to be a safe and effective intervention.” Authors of a study state that “Patients undergoing gender-affirming mastectomy in this single-center prospective study reported significant improvements in anxiety, depression, body image, psychosocial, and sexual functioning after this procedure. Patients were extremely satisfied with the decision to undergo this operation.” Experts state that “Obesity alone should not be considered a contraindication for gender-affirming mastectomy. Attention should be given to several modifiable risk factors identified in this study, including lesser incision surgical techniques, tobacco use, and testosterone use.” Overall, gender-affirming subcutaneous mastectomy is generally indicated for transgender patients assigned female at birth, and this patient meets WPATH requirements for the procedure. According to the literature, the patient’s obesity is not a contraindication for this procedure. Gender-affirming subcutaneous mastectomy for this patient is in accordance with the generally accepted standards of mental health and substance use disorder care, clinically appropriate in terms of type, frequency, extent, site, and duration, and not primarily for the convenience of the patient or provider. All told, the requested gender-affirming subcutaneous mastectomy is medically necessary for the treatment of the patient. Final Result: The reviewers determined that the requested procedure is medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be overturned. Credentials/Qualifications: Reviewer 1 is board-certified in psychiatry with expertise in transgender health. Reviewer 2 is board-certified in plastic surgery and is actively practicing. Each reviewer is an expert in the treatment of the patient's medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN25-46258

7. Overturned 2025 · Medical necessity · age 21–30 Hair removal · Mental health The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for immediate scheduling and initiation of electrolysis or laser hair removal to the chest area.Based on the records provided for…

   The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for immediate scheduling and initiation of electrolysis or laser hair removal to the chest area.Based on the records provided for review, this patient has a history of gender dysphoria. The patient continues to express distress due to gender dysphoria, as noted by the provider, related to the presence of chest hair. One study noted that body hair removal can play an important role in treating gender dysphoria in those assigned male at birth. In addition, the World Professional Association for Transgender Health (WPATH) Standards of Care (SOC), Version 8 states that “We recommend health care professionals offer transgender and gender diverse people referrals for hair removal from the face, body, and genital areas for gender-affirmation or as part of a preoperative preparation process”. Overall, the WPATH SOC does not have a specific requirement regarding the length of time a patient should be treated with hormones before undergoing hair removal. Although at least one year on hormones is a common interval, some nonbinary patients have body hair removal as a treatment for gender dysphoria without receiving treatment with hormones. In this case, the patient has been on hormones for a couple of years, according to the available records. Despite treatment with hormones, the patient’s gender dysphoria persists. Thus, the requested immediate scheduling and initiation of electrolysis or laser hair removal to the chest area is supported as medically necessary. Furthermore, the requested immediate scheduling and initiation of electrolysis or laser hair removal to the chest area is medically necessary to achieve age-appropriate growth and development, and attain, maintain, or regain functional capacity. Given these findings, the requested immediate scheduling and initiation of electrolysis or laser hair removal to the chest area is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be overturned. Credentials/Qualifications: The reviewer is board-certified in psychiatry with expertise in transgender health and is actively practicing. The reviewer is an expert in the treatment of the patient’s medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN25-46249

8. Overturned 2025 · Medical necessity · age 41–50 Mastopexy · Kidney and urinary The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for mastopexy performed during a lumpectomy procedure. The medical literature pertaining to breast cancer reconstruction reveals that breast…

   The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for mastopexy performed during a lumpectomy procedure. The medical literature pertaining to breast cancer reconstruction reveals that breast reconstruction results in improvement in quality of life (QOL). Researchers report that QOL scores improve dramatically after breast reconstruction for patients who initially had not had breast reconstruction. A study demonstrated that mastectomy followed by reconstruction preserved the QOL, if reconstruction was proposed for certain types of patients, such as those of young age. In this case, the patient was young and fell into this subgroup. With regard to mastopexy for symmetry, the medical literature demonstrates that immediate symmetrization surgery does not increase revision surgery and complication rates, or decrease satisfaction levels. Overall, the revision lateral intercostal artery perforator (LICAP) flap lumpectomy reconstruction and mastopexy for symmetry were indicated for the treatment of the patient. Accordingly, the mastopexy performed during a lumpectomy procedure was medically necessary for the treatment of this patient.The California reconstructive surgery statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function; or (2) to create a normal appearance to the extent possible. In this case, the patient presented with flat epithelial atypia (FEA)/atypical ductal hyperplasia (ADH), which constitutes an abnormal structure of the body caused by cancer/tumor. The mastopexy performed during a lumpectomy procedure restored the appearance of the patient after destructive breast surgery. LICAP flap restored the natural appearance of the breast and the mastopexy restored the symmetry. Further, the flap was a major procedure and provided more than a minimal improvement in appearance, and was restorative for the patient’s physical and mental wellness. All told, the mastopexy performed during a lumpectomy procedure was supported as reconstructive in nature for the treatment of this patient.Therefore, the mastopexy performed during a lumpectomy procedure was medically necessary and reconstructive in nature for the treatment of this patient. Final Result: The reviewer determined that the service at issue was medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be overturned. Credentials/Qualifications: The reviewer is board-certified in plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the patient's medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN25-46238

9. Overturned 2025 · Medical necessity · age 21–30 Facial feminization surgery · Mental health The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for facial feminization surgery, hair restoration surgery, and vocal surgery to be performed in a single operative session. Per the…

   The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for facial feminization surgery, hair restoration surgery, and vocal surgery to be performed in a single operative session. Per the medical records, the patient has a diagnosis of gender dysphoria. In this case, the requested services are in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the requested services are clinically appropriate in terms of type, frequency, extent, site, and duration. The requested services are not primarily for the economic benefit of the health care service plan and subscribers or for the convenience of the patient, treating physician, or other health care provider. Therefore, facial feminization surgery, hair restoration surgery, and vocal surgery to be performed in a single operative session are medically necessary to protect life, to prevent significant illness or significant disability, or to alleviate severe pain. Final Result: The reviewer determined that the requested services are medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be overturned. Credentials/Qualifications: The reviewer is board-certified in plastic surgery with expertise in transgender health and is actively practicing. The reviewer is an expert in the treatment of the patient's medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN25-46225

10. Overturned 2025 · Medical necessity · age 41–50 Implant removal · Kidney and urinary The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for left breast surgery including anesthesia. Per the medical records, the patient had an intracapsular rupture of a silicone gel breast…

    The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for left breast surgery including anesthesia. Per the medical records, the patient had an intracapsular rupture of a silicone gel breast implant. As such, capsular revision and the removal of implant/implant contents were medically indicated. Therefore, revision of the peri-implant capsule in the breast and removal of a ruptured breast implant were medically necessary for the treatment of this patient. The records indicate that the patient also underwent a left breast mastopexy. Given that reduction mammaplasty, referring to mastopexy, is a cosmetic procedure, reduction mammaplasty, was not medically necessary for the treatment of this patient. Final Result: The reviewer determined that a portion of the services at issue were medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be partially overturned. Credentials/Qualifications: The reviewer is board-certified in plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the patient's medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

    Case MN25-46219

11. Upheld 2025 · Medical necessity · age 51–64 Other · Bones, joints and muscles The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for reconstruction surgery of the thorax. Upon review of the provided documentation, there is a lack of sufficient clinical…

    The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for reconstruction surgery of the thorax. Upon review of the provided documentation, there is a lack of sufficient clinical indication for surgical intervention at this time. Magnetic resonance imaging of the cervical and thoracic spine was unremarkable. Magnetic resonance imaging of the lumbar spine showed mild stenosis of L4-L5. Computed tomography of the chest did not reveal any significant bony abnormalities, and initial rib and chest wall series were negative for fractures. In the absence of any significant deformities or structural abnormalities requiring correction, surgical intervention is not warranted. This supports a lack of indication for restoration of abnormal anatomy or external cosmesis. Given these findings, the requested reconstruction surgery of the thorax is not medically necessary and is not reconstructive in nature for the treatment of this patient. Final Result: The reviewer determined that the requested procedure is not medically necessary and is not reconstructive in nature for the treatment of the patient’s medical condition. Therefore, the Health Plan’s denial should be upheld. Credentials/Qualifications: The reviewer is board-certified in thoracic and cardiac surgery and is actively practicing. The reviewer is an expert in the treatment of the patient’s medical condition and is knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

    Case MN25-46139

12. Upheld 2025 · Medical necessity · age 51–64 Excess skin removal · Skin The physician reviewer found that a patient has requested authorization and coverage for a panniculectomy. In this case, the patient has a three to four-centimeter abdominal pannus following pregnancies and caesarean sections (C-sections). A review of the…

    The physician reviewer found that a patient has requested authorization and coverage for a panniculectomy. In this case, the patient has a three to four-centimeter abdominal pannus following pregnancies and caesarean sections (C-sections). A review of the patient's photograph reveals that the patient’s pannus does not overhang the pubis. The patient reported being prone to rashes and using an anti-fungal, over-the-counter Desitin cream and baby powder for rashes. However, the provider’s physical examination of the patient does not indicate evidence of a rash. Furthermore, there is no report of medical treatment needed for rash or of failure of medical treatment of a rash. In addition, there is no report of chronic skinfold maceration without response to oral or topical treatment for at least three months. As such, the requested panniculectomy is not medically necessary for the treatment of this patient. The California reconstructive surgery statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function; (2) to create a normal appearance, to the extent possible. The record establishes that the patient has lax abdominal skin after pregnancy and weight loss. An abdominal pannus following pregnancy and weight loss is not an abnormal structure of the body. It is a normal accommodation to pregnancy and to gain and loss of body mass. It is not caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease. Thus, the requested panniculectomy is not reconstructive in nature for this patient.All told, the requested panniculectomy is not medically necessary and not reconstructive in nature for the treatment of this patient. Final Result: The reviewer determined that the service is not medically necessary and not reconstructive in nature for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be upheld. Credentials/Qualifications: The reviewer is board-certified in plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the patient's medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

    Case MN25-46044