Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skin Disorders/ Other/Panniculitis.
Treatment: Surgical Services.
The health plan denied the requested surgical procedure as not medically necessary. The health plan's determination is upheld.

This female underwent bariatric surgery, subsequently lost weight and now complains of a hanging abdominal pannus with associated rashes. Powder and over the counter medications have not provided relief. At an examination there was a supraumbilical pannus hanging over the umbilicus with periumbilical intertrigo and an infraumbilical pannus hanging over the mons pubis. Pannus dimensions were 65x21 centimeter (cm). Photos show the pannus but photo quality does not allow assessment of the skin condition.

The patient's surgeon has proposed abdominoplasty surgery. Coverage was denied as the surgery is defined as not medically necessary.
At issue is the medical necessity of the requested procedure.

The health plan's determination of medical necessity is upheld, in whole.

Per Milliman Care Guidelines (MCG) Health Ambulatory Care 25th Edition Abdominoplasty ACG: A-0497 (AC):
Abdominoplasty may be indicated when ALL the following are present:
1- Abdominal wall laxity or skin excess interferes with activities of daily living. [NOT MET].
2- Patient has complications from a panniculus (i.e., chronic or recurrent intertrigo, other skin infection, ulceration, or skin irritation that has been persistent despite nonsurgical treatment). [NOT MET].
3- Patient's weight has reached stable plateau, and 1 or more of the following:
-Adherence to multidisciplinary nonsurgical program of weight maintenance.
-One year or more has elapsed following bariatric surgery. [MET].
Therefore, the overall criteria are not met; abdominoplasty is not medically necessary.

InterQual criteria are a first level screening tool to assist in determining if proposed services are clinically indicated and provided in the appropriate level or whether further evaluation is required. They are based on medical literature and updated yearly. The InterQual criteria for panniculectomy are age 18 or greater and:

A) Post bariatric procedure and panniculus extends below the level of the symphysis pubis
     1- age 18 years old or older [MET ]
     2- 1 or more years since bariatric surgery [MET ] AND
     3- Weight stable for 6 or more months [MET ] AND
     4- A) Inability to maintain hygiene of lower abdominal and genital area [NOT MET] OR
        B) Nonhealing ulceration under panniculus [NOT MET] OR
        C) Chronic maceration or necrosis of overhanging skin folds [NOT MET] OR
        D) Recurrent or persistent skin infection under panniculus [NOT MET because medical treatment is not documented] OR
        E) Intertriginous dermatitis or cellulitis or panniculitis [NOT MET by physical examination or photos] AND
     5- A) Local or systemic antibiotic treatment 12 or more weeks did not work [NOT MET] OR
        B) Topical or systemic corticosteroid treatment 12 weeks or more not work [NOT MET ] OR
        C) Topical antifungal medication treatment 12 weeks or more not work [NOT MET } AND
     6- photo documentation submitted [MET]
Therefore, the overall coverage criteria are not met, and the surgery is not medically necessary.