Balancing Expectations: Navigating Medically Necessary Torso Procedures with Cosmetic Components in the Military Healthcare System

Abstract

Background:

Surgeons performing federal insurance–financed procedures involving medically necessary and cosmetic components must navigate patient expectations to avoid postoperative disappointment. This challenge is amplified in military healthcare, where different surgical specialties concurrently address the same diagnosis, while the Department of Defense policy on cosmetic fees and TRICARE’s definition of excluded services adds further complexity. With the increasing prevalence of elevated body mass index, focus is directed toward diagnoses involving the torso, specifically gynecomastia in male individuals, and diastasis of the rectus abdominis muscles (DRAM) in female individuals.

Methods:

The study involves a team of experienced board-certified surgeons conducting a narrative review of surgical procedures addressing gynecomastia and DRAM. Relevant literature from 2000 to 2023 is reviewed, focusing on patient satisfaction regarding outcome of medically necessary and cosmetic aspects.

Results:

For gynecomastia, distinguishing between true and pseudogynecomastia is critical. A protocol is presented based on the Simon classification, offering evidence-based guidelines for surgical interventions. Similarly, for DRAM, a minimally invasive approach balances deployment readiness and surgical recovery. The presence of a symptomatic panniculus, however, requires more invasive intervention. The downstream ramification of limited Current Procedural Terminology codes for these interventions is discussed.

Conclusions:

In medically necessary procedures funded through federal health plans such as TRICARE, the primary goal is functional improvement, not the final torso contour. Clear communication and preoperative counseling are crucial to managing patient expectations. Providers in military healthcare must navigate the complex landscape of patient expectations, policy guidelines, and duty readiness while maintaining the standard of care.

Takeaways

Question: In military healthcare, how can surgeons effectively balance performing medically necessary torso procedures that have cosmetic components?

Findings: Surgeons in military healthcare face challenges performing torso procedures that are medically necessary but include cosmetic elements. Balancing patient expectations, adhering to policy guidelines, and managing functional outcomes alongside aesthetic considerations is crucial.

Meaning: Surgeons must navigate complexities in offering procedures with cosmetic components, especially in military healthcare, where maintaining service member readiness is vital. Understanding nuances between medical necessity and cosmetic procedures while communicating effectively with patients is essential for successful outcomes and ensuring policy compliance.

INTRODUCTION

Surgeons performing federal insurance–financed procedures on the torso, deemed medically necessary but involving maneuvers with cosmetic components, must be vigilant about potential patient disappointment arising from misunderstood expectations. Throughout the planning, execution, and recovery phases of such procedures, awareness of the mutually derived endpoint anticipated by surgeon and patient should be revisited. The relationship between a surgeon and patient becomes more complex when planning a medically necessary procedure with cosmetic components, especially when different surgical specialties with overlapping skill sets and various approaches exercise privileges addressing the same diagnosis. The uniformed services healthcare program, TRICARE, covering active-duty service members (ADSMs), qualified retirees, and dependents, adds complexity to this interaction, given the core mission of building and maintaining service member readiness.¹ Although justifications regarding the medical necessity of certain torso procedures may consider position descriptions of ADSMs, surgeons must adhere to policies without compromising the standard of medical care.² The impact of offering surgery with cosmetic components must be assessed, especially considering the competing demands during conflict versus peacetime.^3,4

Understanding the Cosmetic Component of a Procedure

At the military treatment facility level of care, Department of Defense policy parses plastic surgery into cosmetic, involving reshaping normal structures to improve appearance or self-esteem, and reconstructive, enhancing function while possibly approximating normal appearance.⁵ This policy requires all patients undergoing cosmetic surgery to pay fees, whereas reconstructive surgery is a covered benefit. For beneficiaries of military healthcare seeking medically necessary care in the civilian system, plastic surgery is defined as surgery that improves physical appearance, addresses psychological concerns, or restores form. Such procedures are solely cosmetic and excluded from coverage.⁶ Improving quality of life does not meet medical necessity according to these policies. Only procedures performed to correct a bodily function or a specifically enumerated exception (eg, congenital anomaly, disfiguring scar, breast reconstruction) are covered by TRICARE. TRICARE coverage is based on medical necessity, which is defined as the need to treat a condition or its consequences while adhering to accepted standards, rather than a specific diagnosis. Criteria do not exist requiring a level of severity to achieve coverage, but rather, simply the presence of problematic symptoms.⁷ The use of liposuction as a substitute for scalpel is permitted in any medically necessary procedure by TRICARE and does not define a cosmetic procedure. Therefore, surgeons from any specialty performing medically necessary procedures while involving potential aspects of cosmetic surgery must be mindful of the Department of Defense policy regarding cosmetic fees and the TRICARE definition of excluded services.

With the rising average body mass index among United States citizens, including the military,⁸ two diagnoses involving the torso present uncertainty with regards to medical necessity: gynecomastia for male individuals and diastasis of the rectus abdominis muscles (DRAM) for female individuals. Furthermore, both these diagnoses fall within the scope of practice for general or plastic surgeons; specialists who possess very different technical armamentariums pursuing a wide range of procedural endpoints. We present an evidence-based protocol to navigate these conditions in the active-duty military population, dependents, and qualified retirees with a focus on avoiding postoperative disappointment.

METHODS

The research team for this study consisted of four authors, all of whom are board-certified surgeons with expertise in either general or plastic surgery. The collective experience of the authors spans greater than four decades, ensuring the comprehensive evaluation of surgical procedures addressing gynecomastia and DRAM.

The main goal of this narrative review was to examine those procedures commonly performed across various surgical specialties to treat benign diagnostic conditions affecting the torso, which are exacerbated by increasing body weight due to normal aging. The review aimed to differentiate between the medically necessary and cosmetic aspects of these procedures, delineating downstream consequences.

A thorough search was conducted to identify relevant articles from peer-reviewed journals using the National Library of Medicine MEDLINE/PubMed electronic database. The search was executed using Medical Subject Headings terms, keywords, and Boolean operators. The search terms used “torso surgery,” “gynecomastia surgery,” “diastasis rectus abdominis muscle surgery,” “criteria for medical necessity,” “criteria for cosmetic surgery,” and “weight gain trends.”

Inclusion criteria for studies were as follows: published 2000 to 2023, written in English, and addressing surgical procedures treating gynecomastia or DRAM. Exclusion criteria included studies not related to the topic of interest, full-text unavailable, and inadequate methodology description. Two authors independently screened and selected studies based on the inclusion and exclusion criteria. In cases of disagreement, studies were included. All four authors participated in synthesizing data narratively to formulate a protocol for patients.

RESULTS

Although 72 articles satisfied the inclusion criteria, only 31 remained after application of exclusion criteria. The survey of these qualifying studies resulted in the following narrative review.

Gynecomastia

True gynecomastia (gland hypertrophy) versus pseudogynecomastia (excess adiposity) must be properly delineated. In cases of pseudogynecomastia, elevated body mass index must be addressed before surgical intervention. In these cases, there is minimal subareolar glandular tissue palpable while regions with typical fat deposition (eg, abdominal flanks) demonstrate hypertrophy. Surgical treatment of pseudogynecomastia solely to improve body image is a cosmetic undertaking and does not meet medical necessity.

Management of new-onset gynecomastia in ADSMs requires a focused medical work-up despite the plurality of cases being idiopathic. Breast cancer, neurofibroma, lipoma, and cyst must be excluded. Known pathophysiology such as hypogonadism, thyrotoxicosis, hypothyroidism, liver disease, or kidney disease should be ruled out via disease-appropriate testing if symptomatically indicated.⁹ Blanket screening for biochemical etiologies is low yield in the ADSM population except for morning serum total testosterone. A low morning serum total testosterone will trigger further evaluation, including repeat testing in addition to free testosterone, gonadotropins luteinizing hormone, and follicle stimulating hormone.¹⁰ Consideration of elevated prolactin, although rare, is reasonable. Common medications used by ADSMs, including finasteride, spironolactone, ketoconazole, and omeprazole, may alter androgen synthesis.¹¹ Meanwhile abused substances such as alcohol, amphetamines, marijuana, anabolic steroids, or over-the-counter hormones—although not easily elicited from the history of an ADSM—are associated with gynecomastia.^12,13 Use of tamoxifen to mitigate gynecomastia has been described.¹⁴

Gynecomastia generally is asymptomatic but, in some cases, may cause pain, tenderness, or sensitivity. Medical necessity for surgical treatment of those patients with federal health insurance should be justified within the medical record beyond only the narrative of the operative surgeon in case there is a request for utilization review either before or after the procedure is performed. Many patients with commercial health insurance who are deemed suitable for surgery by the operative surgeon are often denied this necessary authorization.¹⁵ Solely naming interference with position description as a justification for surgery, such as utilization of ballistic plates, is inadequate. The dimensions of male and female vests differ along the torso. Further documentation of failed garment fitting trials is also appropriate.¹⁶

Once medical justification for treatment is satisfied, given the concrete definition of cosmetic surgery, the endpoint for the operative procedure must not focus on physical appearance; otherwise, treatment requires institution of cosmetic fees.¹⁷ As deployment readiness and surgical recovery are mission critical in military healthcare but diametrically opposed forces, open treatment of gynecomastia is arguably contraindicated if minimally invasive options are readily available to address the medically necessary diagnosis. The predominant classification system for gynecomastia was described by Simon¹⁸ (Table 1).

Table 1.

The Simon¹⁸ Classification of Gynecomastia Is Based on Gland Volume and Skin Quality

Simon Classification of Gynecomastia
Grade	Gland Enlargement	Skin Excess
I	Small	None
IIa	Moderate	None
IIb	Moderate	Yes
III	Marked	Yes

For grade I or IIa gynecomastia, not only does liposuction treatment with pull-through technique adequately remove and contour tissue, but it also has a faster recovery with lower risk profile of hematoma and necrosis due to its minimally invasive approach.^19,20 This procedure marries minimally invasive liposuction with various equipment (traditional, ultrasound, power, VASER) and blunt gland removal using grasping tools through the liposuction access site.²¹ Moreover, in the case of grade I or IIa gynecomastia, whereas strictly sharp excision risks the feared postoperative contour deformity with saucer-type depression, liposuction with pull-through technique does not. Therefore, in grade I or IIa gynecomastia, liposuction with pull-through technique should be the preferred method of treatment for ADSMs. Avoiding skin elevation in favor of liposuction while performing medically necessary gynecomastia treatment in the ADSM population eschews the pathognomonic chest wall scars. These scars from open gland resection increase recuperation time. Additionally, these scars could be inappropriately stereotyped as originating from gender affirming mastectomy. Nevertheless, utilization of these different techniques varies between surgeons. All these interventions meet the standard of care.

Cases with greater gland volume and consequent ptosis, such as grade IIb or III gynecomastia, are less frequent in the ADSM population. In these cases, liposuction with pull-through technique adequately addresses tissue reduction, but from a cosmetic vantage, it is unlikely to produce an adequate skin resection or torso contouring.²² In situations with more significant gynecomastia, sharp skin excision such as circumareolar or boomerang techniques must be entertained to successfully achieve a pleasing postoperative torso appearance.^23,24 However, for medically necessary procedures in ADSMs, the complete elimination of gynecomastia with simultaneous cosmetic enhancement of the torso utilizing skin contouring is not the approved outcome metric. In these situations, the targeted endpoint is relegated to improvement of symptoms through adequate reduction of gland volume. To avoid postoperative disappointment, the desired endpoint must be clearly established (Table 2).²¹

Table 2.

Endpoints of Symptom Relief and Contour Improvement for Liposuction versus Open Surgical Treatment of Gynecomastia based on Simon¹⁸ Classification as Abstracted Through This Narrative Review

Gynecomastia Treatment Options
Simon Grade	Liposuction with Pull-through		Open Sharp Contouring
	Relief of Symptoms	Improved Contour	Relief of Symptoms	Improved Contour
I	Yes	Yes, incidental	Yes	Possible decrement
IIa	Yes	Yes, incidental	Yes	Possible decrement
IIb	Yes	Maybe	Yes	Yes
III	Yes	Unlikely	Yes	Yes

From the perspective of equity, active-duty female individuals similarly seek medically necessary breast reduction for symptomatic hypertrophy but without complete gland removal, so too should active-duty male gynecomastia treatment leave behind glandular tissue. Additionally, in the medically necessary female breast reduction, although ptosis is improved, the primary goal is not elevation of the nipple above the inframammary fold. Limited reduction of gland size in a reliable and efficient manner to ameliorate symptoms is the sole medically necessary goal, regardless of whether male or female individuals. The cosmetic symmetric appearance of absent glandular tissue with tightened skin in the male torso is not medically necessary.^25,26 If cosmetic torso contour is a specifically enumerated outcome goal for the patient, the portion of the surgical procedure with sharp skin excision requires application of cosmetic fees as per TRICARE policy.

Diastasis of the Rectus Abdominis Muscle

DRAM is defined as laxity of varying horizontal degrees and/or locations in the midline abdominal aponeurosis from the subxiphoid to suprapubic regions. This is slack of the rectus abdominis aponeurosis, not hernia. Etiologies include increased intraabdominal pressure due to pregnancy, obesity, or age. In the ADSM population, most patients with DRAM are postpartum female individuals.

DRAM is a clinical finding upon physical examination of a protruding abdomen and is easily elucidated with a sit-up/curl-up maneuver. Healthcare providers must remain cognizant that a simultaneous true ventral hernia, from a defect in the fascia, may remain concealed. The presence of a ventral hernia changes the treatment algorithm. If required, imaging is obtained with ultrasound, computed tomography, or MRI. There are numerous classification systems in use for DRAM, but none corroborate symptoms.²⁷ Consequentially, rigorous comparative studies of interventional technique versus outcome are lacking.^28–30

Functional symptoms thought to be associated with DRAM are core weakness or urinary incontinence leading to a decreased quality of life.³¹ DRAM generally resolves in postpartum women but can persist. Targeted physiotherapy is associated with improved symptoms, but statistical evidence is unclear.³² There are growing studies of functional improvement in quality of life on an individual level following surgical intervention.^33–35

DRAM repair is not a cosmetic service if symptoms are present.³⁶ Therefore, medical necessity for repair can be satisfied if this diagnosis is linked to objective symptoms, which interfere with activities of daily living and fail to improve with nonsurgical interventions. Aesthetic dissatisfaction of the abdominal contour due to protrusion is a common subjective symptom of DRAM but not enough to justify medical necessity of repair.

There are a variety of options for repair of DRAM. The muscle laxity may be approached via traditional open or minimally invasive laparoscopic/robotic intervention. The open approach involves either a midline incision for direct exposure or a horizontal incision placed caudally with superiorly based reflection of the abdominal flap to camouflage the scar. The minimally invasive technique uses laparoscopic or robotic approaches with insufflation of soft tissue to gain exposure. Regardless of the technique—once visualized—the muscle laxity can be repaired in a single or double-layered fashion with permanent or absorbable sutures, interrupted or running, with or without Medical Subject Headings, in an anterior or retro-rectus preperitoneal manner. There are simply no studies producing clear distinctions as to superiority of any single technique.³⁷ Each technique meets the standard of care.

Isolated DRAM in the ADSM population is arguably best managed with a minimally invasive approach to balance deployment readiness and surgical recovery.³⁸ Although rigorous studies are lacking, robotic retroperitoneal repair may provide an expedited recovery.³⁹ This approach, however, does not address redundant skin.

Decision-making algorithms for the method of DRAM repair must also consider the presence or absence of a panniculus, which potentially exacerbates symptoms. In cases with simultaneous panniculus intervention, transposition of the umbilicus becomes an issue based on the severity of skin excess and tone. Addressing the panniculus with excision takes away from deployment readiness due to the additional recuperation time required for soft tissue undermining and skin advancement. Nevertheless, when a panniculus is observed, intertrigo may accompany. Additional documentation of medical necessity can justify resection during DRAM repair because it improves the overall integrity of the skin. An objective classification system of abdominal contour deformity exists, known as the Pittsburgh Rating Scale.⁴⁰ However, its overall applicability to the ADSM population is limited because it is geared toward massive weight loss patients and does not articulate aspects of DRAM.⁴¹

Adding further opacity to DRAM management is that there is only one Common Procedural Terminology (CPT) code used in the United States for plication of the rectus with resection of the panniculus and transposition of the umbilicus (CPT 15846). This CPT is defined as abdominoplasty. The downstream consequence is that commercial health insurers rarely, if ever, approve DRAM repair for functional reasons because they only recognize abdominoplasty as cosmetic.⁴² This limited coding clouds preoperative counseling with patients about expectations of appropriate endpoints due to confusing terminology and misleading threads on internet blogs.⁴³ An applicable CPT code for isolated repair of DRAM is 49999. This is listed as “other” procedure. An isolated abdominal panniculectomy code also exists (CPT 15830). Using CPT 49999 as an add-on code with the abdominal panniculectomy code could be interpreted as unbundling and does not account for the umbilical transposition. Therefore, the authors urge use of the term medically necessary (or functional) abdominoplasty. This would be a helpful addition to the nomenclature. When performing a medically necessary abdominoplasty to address both DRAM and panniculus with transposition of the umbilicus, placement of waist-cinching plication sutures or lateral liposuction to improve final torso contour clearly ventures into cosmetic territory.⁴⁴ Although the cosmetic abdominoplasty techniques exceed the foundational maneuvers of a functional abdominoplasty, the CPT coding remains static (Table 3).⁴⁵ This major shortcoming in coding should be rectified.

Table 3.

Endpoint Outcomes for Repair of DRAM, Resection of Panniculus and Contouring of the Torso Listed for Various Abdominal Procedures with CPT Coding as Abstracted Through This Narrative Review

Surgical Procedure	Endpoint Outcome
	Repair DRAM	Resect Pannus	Contour Torso
Open or minimally invasive DRAM repair (CPT 49999)	Yes	No	No
Panniculectomy (CPT 15830)	No	Yes	No
Medically necessary abdominoplasty (CPT 15847)	Yes	Yes	No
Cosmetic abdominoplasty (CPT 15847)	Yes	Yes	Yes

DISCUSSION

Unlike those individuals covered by most commercial health plans, TRICARE beneficiaries with medically necessary needs involving gynecomastia or DRAM can have their diagnoses addressed surgically. However, the outcome metrics for these insurance-covered procedures are in fact different from what is anticipated in the aesthetic environment. This does not mean the standard of care is different, but rather, it is the procedural endpoint. If poorly communicated preoperatively, this potentially creates postoperative physician–patient misunderstanding.

In the treatment of gynecomastia or DRAM under the aegis of medically necessary coverage, functional improvement of the patient is the sole measured goal, not the final torso contour. Certainly, the contour incidentally and frequently changes for the better as the functional problem is addressed. However, the expectation of complete correction of the dissatisfactory contour by the patient must not be held out as the primary goal, unlike in the cosmetic surgery population. Indications for the procedure through medical necessity is improvement of function, not form. Simultaneously, surgical techniques used with ADSMs must weigh rapid recovery to maximize military readiness while simultaneously adhering to the standard of care. Accordingly, this favors minimally invasive procedures (such as liposuction or robotic assisted procedures) over resection and mobilization of large, soft tissue volumes. Although leaving residual excess ptotic skin is eschewed, there must be an acknowledgment by ADSMs of the procedural goals. Because understanding and accepting residual ptotic skin is a subjective process, appropriate preoperative counseling is paramount. Expecting a smooth and tight contour postoperatively by the soldier-patient forays into an aesthetic procedure and necessitates initiating cosmetic fees with recognition of the desired endpoint. Although encouraging minimally invasive maneuvers over open surgery may bypass cosmetic surgery fees and improve soldier-patient readiness, the expectations of the patient are critical regarding outcome. Simultaneously, soldier-surgeons must be aware of implicit bias that may favor recommending open procedures that improve deployment-related skills.⁴⁶ The focus must never waver from recommending the appropriate surgery for the problem using best clinical practices and following the standard of care.

Further ethical conflict arises when treating qualified retirees or dependents covered by TRICARE with these same diagnoses. Establishing medical necessity for these individuals follows the same criteria as for ADSMs. The treatment algorithms do not change. What is covered by insurance remains limited to only improved function. Exploration preoperatively of surgical expectations cannot be overemphasized. A spouse seeking abdominoplasty will have different expectations from an ADSM, especially if fee-for-service aesthetic consultations are simultaneously sought outside a military treatment facility enterprise. Nevertheless, the onus remains on providers of military healthcare to educate the patient regarding appropriate surgical endpoints with medically necessary procedures.

CONCLUSIONS

The unique population encountered by providers of military healthcare in military treatment facilities (ADSMs, dependents, and qualified retirees) potentially obfuscates procedural outcome metrics, as stakeholders have competing interests. Surgeons must follow policy guidelines establishing medical necessity or initiate cosmetic fees while simultaneously discussing duty readiness, whereas patients seek outcomes that may overemphasize final torso contour. It is critical to walk this tightrope ethically while achieving appropriate patient satisfaction, maintaining the standard of care, and guaranteeing the readiness of both soldier-patient and soldier-surgeon.

DISCLOSURE

The authors have no financial interest to declare in relation to the content of this article.

ACKNOWLEDGMENTS

The authors thank Col Neil R. McMullin, MD, FACS, Consultant to the Surgeon General for Plastic Surgery. Approval for exemption was obtained from the Martin Army Community Hospital exemption determination official.