Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for panniculectomy. The American Society of Plastic Surgeons (ASPS) has indicated that the criteria for the treatment of panniculectomy include documentation that the panniculus hangs below the level of the pubis and that the panniculus causes chronic intertrigo that consistently recurs over three months despite appropriate medical therapy. The photographs provided for review demonstrate that this patients panniculus hangs well below the level of the pubis. There are sores both in front of the abdominal pannus and underneath the abdominal pannus. Although there is mention of use of Nystatin, the records do not document the presence of chronic intertrigo that consistently recurs over three months despite appropriate medical therapy. The patient requires excision of the abdominal pannus in order to be considered for left hip surgery. The patient does not require a panniculectomy before his weight reaches a BMI of 35 kg/m2, which is a medically appropriate requirement. Researchers state that, post bariatric surgery patients should approach normal and stable weight and present with low-fat content of the excess skin. The authors noted that a strong consensus exists postulating a BMI at least smaller than 35 kg/m2. Studies found that in patients undergoing post-bariatric body contouring procedures, the perceived benefit despite major risk of complication may confound the risk-benefit ratio of undergoing such procedures. The authors discussed that the overall complication rate was significantly greater in patients with a higher pre-panniculectomy BMI. This patients providers have recommended that the patient wait to undergo a panniculectomy until his BMI is less than 35 kg/m2. This recommendation is consistent with the current medical literature and guidelines. Thus, the requested panniculectomy is not medically necessary for treatment of this patient. The California reconstructive surgery statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function; (2) to create a normal appearance, to the extent possible. An abdominal pannus is not a result of a congenital defect, a developmental abnormality, trauma, infection, tumors or disease. The patients pannus is not an abnormal structure of the body, rather a normal structural change that is an accommodative response to gain or loss of body mass. The appearance of the patient is normal and consistent with the gain and loss of weight. The requested procedure would make a more than minimal improvement in the patients appearance. However, as his BMI is more than 35 kg/m2, the risks associated with the requested procedure outweigh the expected improvement in the patients appearance. Given these findings, the requested panniculectomy is not reconstructive in nature for treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary and not reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.