Are there medical reasons (medical necessity) to have a brachioplasty? (photos)

Question

Right before I was diagnosed with breast cancer, my upper arms developed "bat wings." In the last few years, they have gotten much worse. (My PCP thinks that each arm has roughly 7 - 8 pounds of fat.) I have recently lost over 150 pounds - I have lost inches ALL over, but not my arms. Arm movement is awkward, I get heat rashes, have upper arm and shoulder pain.

J. Timothy Katzen, MD, FACS · Answer

Yes, there are medical reasons to necessitate an arm reduction or brachioplasty. Over the past 15 years I have had a significant number of patients authorized by their insurance companies for arm reduction or brachioplasty due to redundant, excess upper arm skin and fat. Insurance approval depends on your anatomy, history, medical plan, strength of your plastic surgeon’s letter requesting for arm lift surgery, and the eventual approval by hopefully, a medical doctor in your insurance plan. Please note, however, there are no rules and every insurance plan has their own individual rules. To make matters even more confusing, every state also has independent rules requiring medical coverage for certain conditions. I have often had arm reductions or brachioplasties covered by insurance if the patient can document rashes and difficulty keeping the axillary region clean. In addition, I have been able to get approval from insurance companies for brachioplasty if  my patient can prove that their arms interfere with activities of daily living. I had one patient get authorized for surgery because she was a cook and kept burning her arms on the stove. I had another patient who was required to wear uniform at work. Due to the size of her arms, she could not fit into the required uniform.  Because of this situation, her work insurance had to authorize her arm reduction surgery.Based on your pictures, I would hope any and all medical insurance plans would cover your arm lift or brachioplasty.I hope this answers your question regarding insurance coverage for arm lifts, arm reductions, and brachioplasties.  Good luck! If you have any more questions regarding your arm lift or insurance, please contact my office. Sincerely, Dr. Katzen.

Charles Galanis, MD · Answer

Thanks for your question and the accompanying photos.  Without question you would benefit from a brachioplasty.  Unfortunately, even in the context of pain and frequent documented infections, it has become increasingly difficult to have insurance cover body contouring procedures.  It really varies from insurance company to insurance company but overall the trend is the same.  The best you can do is have a plastic surgeon and your primary provider write letters including ICD-9 (diagnosis) and CPT (planned procedure) codes with photographs to your insurance company and hope for the best.  I am sorry I couldn't be more helpful!   Good luck!

Richard H. Tholen, MD, FACS · Answer

Anatomically, the presence of this degree of upper arm tissue makes brachioplasty the only surgical option appropriate for you (all other health items being okayed first). Your previous breast cancer, unless it was bilateral, appears to have had little or nothing to do with the severity or development of this tissue, nor has it responded to your massive weight loss (congratulations on the weight loss!).As Dr. Burns has stated, axillary lymph node dissection (ALND) may make the risk of lymphedema higher on that side, but the degree of present tissue excess is as much as pretty severe post-surgical lymphedema. I think that brachioplasty is not necessarily contraindicated in the setting of ALND, since the scar is linear, not circumferential. Dissection and undermining need to be limited, and the surgical planning needs to be precise. The potential decrease of tissue load and poor lymphatic flow/drainage in the present tissue excess actually make a relative case FOR brachioplasty, though lymphedema is indeed a consideration.As far as insurance covering brachioplasty, see one or more ABPS-certified plastic surgeons and find out if prior authorization can get approval. Even if not covered, I would consider this a worthwhile investment of your own funds (self-pay) if the rest of your evaluation and work-up make this surgery something to consider. I think there is a possibility that brachioplasty is a good option for you, irrespective of insurance coverage, but would need to examine you and obtain a detailed H&P first. Best wishes! Dr. Tholen

Jonathan Amspacher, MD · Answer

It would be very rare for brachioplasty to be a medically covered procedure. You may want to check with your breast surgeon to see if lymph edema is playing a role in your problem. If he thinks it is the. You may benefit some from lymph edema therapy.

John L. Burns Jr., MD · Answer

With your history of breast cancer, we need to know if you had a mastectomy and axillary lymph node dissection.  If you had an ALND then you are not a candidate for a brachioplasty because of the risk of lymphedema.

Joshua A. Halpern, MD, PA · Answer

Thank you for your question. In my opinion you would benefit from a brachioplasty. One would think from your complaints including skin rash and muscalsketial pain this would be covered by insurance. The reality is every insurance companies have different policies. I would recommend that your plastic surgeon summit a letter of medical necessity to your insurance carrier and see what they say. I hope you find this information helpful.

Jeffrey Antimarino, MD, FACS · Answer

I have had only 2 cases of a brachioplasty being covered by insurance and that was for clearly documented cases of severe lymphedema of the upper arms.  These 2 patients were under the care of a lymphedema specialist.  It is a rare situation which is characterized by the entire arm(s) being affected not just the upper arm.   Unfortunately, after viewing your photos, I don't feel an insurance company would entertain the idea of covering your situation.

Julio Clavijo-Alvarez, MD, MPH, FACS · Answer

Congratulations on your weight loss and thanks
for sharing your question and photos.

You have very big arm skin redundancy.
After breast cancer, if you suffer from lymphedema (chronic swelling of the
arms) the whole extremity will get swollen, not just your “bat wings”. This will
dismiss your case under the insurance eyes. In some cases surgery to this area
in the presence of lymphedema may be contraindicated.

Finally, make sure that you have a
consultation with a board certified plastic surgeon that specializes in after
weight loss surgery.

Wishing you the best in your journey

Mark A. Brzezienski, MS, MD, FACS · Answer

I have not had the occasion to submit brachioplasty treatment to a healthcare insurance company for third party payment.  When claims are submitted, "medical necessity" must be outlined. This necessity is described in ICD-9/10 terms.  Correction of a cosmetic deformity is not a medical necessity.If you have had radiation or lymph node dissection as part of your breast cancer management, brachioplasty may increase your risk of lymphedema.  I would advise against brachioplasty in that case.

Amy M. Sprole, MD · Answer

Your situation and history are fairly unusual. I have never come across anyone that qualified for health insurance coverage of brachioplasty for medical necessity, but the details of your case may be worth inquiring about.  Also, history of axillary lymph node dissection for your breast cancer would put you at higher risk for problems if you were to have brachioplasty surgery.

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Are there medical reasons (medical necessity) to have a brachioplasty? (photos)

Answers (10)

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