Coverage Determination for Right Breast Mass Excision and Bilateral Arm Lift
Question 1: Right Breast Mass Excision
The right breast mass excision should be APPROVED as this represents removal of suspected fat necrosis (a complication of the prior breast reduction) under local anesthesia, which constitutes medically necessary treatment of a breast pathology rather than a cosmetic procedure.
Rationale for Approval
The clinical documentation describes two breast masses on the right breast that "appear to be fat necrosis," with one mass being "quite hard and well-localized" near the incision site 1.
Fat necrosis following breast surgery represents a pathologic condition requiring excision for both diagnostic confirmation and symptomatic relief, not a cosmetic concern 1.
The planned excision under local anesthesia in clinic follows standard surgical principles for breast mass removal, where the incision should be over or close to the lesion and of adequate size to allow removal in one piece 1.
This procedure does NOT fall under the cosmetic services exclusion because it addresses a medical condition (suspected fat necrosis/breast mass) requiring histologic diagnosis, not an aesthetic improvement 1.
The procedure is also NOT a complication of a non-covered service under the policy's exclusion #5, because the breast reduction itself would have met current medical necessity criteria (as acknowledged in the case documentation) even though it occurred before coverage began 1.
Question 2: Bilateral Arm Lift (Brachioplasty)
The bilateral arm lift should be DENIED as this represents cosmetic surgery for excess skin following voluntary weight loss, which is explicitly excluded under the obesity-related services exclusion and cosmetic services exclusion.
Primary Denial Reason: Cosmetic Nature
The certificate explicitly excludes "cosmetic treatment undertaken solely to improve the patient's appearance" unless it represents medical/surgical necessity 1.
The arm lift addresses excess skin resulting from an 80-pound weight loss, which is an aesthetic concern rather than a functional impairment causing medical complications 1.
No documentation indicates medical necessity criteria such as chronic intertrigo, ulceration, infection, or significant functional limitation specifically related to the arm skin 1.
Secondary Denial Reason: Obesity-Related Services Exclusion
The certificate specifically excludes "obesity-related services including but not limited to: supplies, equipment or facilities in connection with weight control or reduction" 1.
Brachioplasty following massive weight loss is considered a body contouring procedure related to obesity treatment, falling under this exclusion 1.
Regarding the "Dog Ear" Correction
The planned removal of "a small dog ear laterally from the lateral end of the breast reduction incision" would also be DENIED as this represents revision of a cosmetic deformity from the prior surgery 1.
This minor revision does not constitute medically necessary treatment but rather aesthetic refinement of the previous surgical result 1.
Critical Distinction
The key difference is that the breast mass excision addresses a discrete pathologic finding requiring diagnosis and treatment, while the arm lift addresses cosmetic sequelae of weight loss without documented medical complications 1.
Even though the axillary roll excisions performed during the original surgery might have been considered cosmetic, the current breast mass represents a new medical indication unrelated to cosmetic concerns 1.