Issued and entered March 21, 2003 by Frances K. Wallace, Chief Deputy Commissioner

ORDER

I
PROCEDURAL BACKGROUND

On February 19, 2003, XXXXXXXXXXX (“Petitioner”) filed a request for external review with the Commissioner of Financial and Insurance Services under the Patient’s Right to Independent Review Act (“PRIRA”), MCL 550.1901 et seq. After a review of the material submitted, the Commissioner accepted the request. Because a medical question is central to the proper resolution of the appeal, it was assigned to an independent review organization (“IRO”), as provided in section 11(6) of the PRIRA, MCL 550.1911(6). The IRO submitted its external medical review on March 12, 2003.

Petitioner is a member of Health Alliance Plan of Michigan (“HAP”). Petitioner seeks coverage for her XXXXXXXXX surgery for treatment of her obesity. HAP denied coverage.

II
ISSUE

The issue to be resolved is whether HAP properly denied Petitioner coverage for that surgery.

III
ANALYSIS

Petitioner’s Argument

Petitioner states she has been overweight all her life. She has tried numerous diets and weight loss programs, but all of her attempts have been unsuccessful. As a result of the weight she fatigues very easily and cannot exercise. In addition to fatigue, she has hypertension, hyperlipidemia, severe osteoarthritis, chronic fungus infections, heel spurs, sleep apnea, restless leg syndrome, excessive daytime sleepiness and depression. Additionally, the excess weight was interfering with everyday activities such as driving, tying her shoes, getting out of the tub, and standing up). She believes that if the girth was removed she could begin exercising, maintain her weight more effectively, and resume her daily living activities.

Petitioner’s physician believes the surgery was medically necessary because Petitioner’s morbid obesity places her at higher risk for Type II diabetes. Her doctor also notes that factors such as hypertension and hyperlipidemia put her at risk for coronary heart disease. Since diet modification has not helped Petitioner lose weight, her doctor agrees that surgical intervention is the best option.

Petitioner’s surgeon has noted that “this is a patient who really needs help and this can be done either by bariatric surgery and followed by abdominal surgery or she can have an abdominoplasty and apronectomy as the only procedure.”

Respondent’s Argument

HAP denied coverage for the surgery for two reasons: 1) the surgery performed was cosmetic surgery and cosmetic services are not covered benefits under Petitioner’s subscriber certificate and, 2) the surgery was undertaken without the required prior authorization.

IRO Review

A practicing physician board-certified in plastic surgery reviewed this case for the IRO and concluded that the surgery was not medically necessary to treat her morbid obesity. The reviewer stated,

The abdominal wall liposuction and abdominoplasty are not medically necessary because it did not treat her primary obesity but only limited, localized manifestations; it is an aggressive, somewhat controversial, unproved approach; and an established alternative exists.

Commissioner’s Review

HAP rejected Petitioner’s request for abdominoplasty surgery alleging its contract excludes coverage for cosmetic services. Michigan law however, requires health maintenance organizations (HMO) to cover ”basic health services.” See MCL 500.3501 & MCL 500.3519(3). Basic health services must be covered when “medically indicated”. The Commissioner, therefore, must determine whether abdominoplasty surgery was medically necessary for Petitioner. On this medical question, the Commissioner accepts the conclusion of the IRO that the procedure was not medically necessary.

Aside from the question of medical necessity, the Respondent was within its authority under the certificate to reject the claim because Petitioner had not obtained the required preauthorization. Such preauthorization requirements are common requirements in health plan contracts.

IV
ORDER

The final adverse determination is upheld.

This is a final decision of an administrative agency. Under MCL 550.1915, any person aggrieved by this order may seek judicial review no later than sixty days from the date of this order in the circuit court for the county where the covered person resides or in the Circuit Court of Ingham County. A copy of the petition for judicial review should be sent to the Commissioner of the Office of Financial and Insurance Services, Health Plans Division, Post Office Box 30220, Lansing, MI 48909-7720.