Brachioplasty / Arm Lift - Medical Necessity Criteria
Criteria for documenting medical necessity of brachioplasty (arm lift).
Contents:
- What is brachioplasty?
- Is brachioplasty covered by insurance?
- Medical necessity criteria for brachioplasty (arm lift)
- Frequently Asked Questions
- Is brachioplasty covered by Medicare?
- Does Blue Cross Blue Shield cover brachioplasty?
- Health plan criteria for brachioplasty and other references
What is brachioplasty?
Brachioplasty is a surgical procedure that is used to remove excess/redundant skin from the upper arms. It is also known as an arm lift.
Is brachioplasty covered by insurance?
In most cases, insurance will not pay for brachioplasty because it is considered cosmetic — that is, it is done only to improve appearance and not to address a medical condition — and therefore not medically necessary. However, some health insurance companies may cover brachioplasty in limited situations where the patient meets medical necessity criteria for the procedure.
Medical necessity criteria for brachioplasty (arm lift)
Brachioplasty, or arm lift, is generally considered cosmetic in nature and not medically necessary.
However, as with other procedures involving the surgical removal of excess skin and subcutaneous tissue, brachioplasty may be considered medically necessary when it is documented in the patient’s medical records that he/she meets all of the following criteria:
- The excess arm skin is causing significant physical or functional impairment, such as:
- Inability to perform activities of daily living due to the presence of the excess skin and subcutaneous tissues, or
- Skin infections requiring systemic antibiotics or systemic antifungals that occur at least twice in a 12-month period, or
- Skin necrosis that does not respond well to conventional wound healing interventions such as debridement, or
- Intertriginous skin rashes or skin ulcers that do not heal despite optimal medical management*; and
- The brachioplasty is reasonably expected to be able to resolve the physical or functional impairment.
* Some health plans require that this must have been treated for at least eight weeks under the direction of a dermatologist.
Brachioplasty is unlikely to be covered if the individual only complains of difficulty fitting into clothes, or if the procedure is being done only for the purpose of altering appearance and is unrelated to physical disease or dysfunction.
Frequently Asked Questions
Is brachioplasty covered by Medicare?
Medicare does not currently have a national or local coverage determination that specifically addresses coverage of arm lifts (brachioplasty). However, generally, Medicare does not cover cosmetic surgery, which it defines as “any surgical procedure directed at improving appearance.” Medicare does cover surgery for therapeutic purposes — even when such surgery coincidentally serves a cosmetic purpose as well — so brachioplasty might be covered when it can be proven to be medically necessary.
Does Blue Cross Blue Shield cover brachioplasty?
Subject to the terms and conditions of the patient’s particular plan, a brachioplasty (arm lift) may be covered if it can be proven to be medically necessary based on the patient’s signs, symptoms and functional impairment(s) as documented in his/her medical records. Otherwise, arm lifts are merely considered cosmetic, not medically necessary, and therefore not covered.
Health plan criteria for brachioplasty and other references
- Aetna Criteria for Cosmetic Surgery
- Anthem Blue Cross Criteria for Cosmetic and Reconstructive Services of the Trunk and Groin
- Empire Blue Cross Blue Shield Criteria for Cosmetic and Reconstructive Services of the Trunk and Groin
- MassHealth Guidelines for Medical Necessity Determination for Excision of Excessive Skin and Subcutaneous Tissue
- Medicare Benefit Policy Manual – General Exclusions from Coverage
- Premera Blue Cross Criteria for Cosmetic and Reconstructive Services
- Tufts Health Plan Medical Necessity Guidelines for Reconstructive and Cosmetic Surgery