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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for abdominoplasty, repair of diastasis recti and/or panniculectomy. Findings:  The physician reviewer found that American Society of Plastic Surgeons (ASPS), a panniculectomy involves the removal of hanging excess skin/fat in a transverse or vertical wedge but does not include muscle plication, neoumbilicoplasty or flap elevation. The ASPS stated that, When surgery to remove extensive skin redundancy and fat folds is performed solely to enhance a patients appearance in the absence of any signs or symptoms of functional abnormalities, the procedure should be considered cosmetic in nature and not a compensable procedure. Sachs and colleagues indicated that, A panniculectomy must meet specific criteria to be medically necessary. The pannus must hang below the level of the pubis and be confirmed with photography. Patients must fail medical treatment of intertrigo for three months. Medical treatment includes good hygiene, topical antifungals, corticosteroids, and antibiotics. The role of panniculectomy is to restore normal function. Patients must maintain a stable weight for at least 6 months. After bariatric  surgery, patients must maintain a stable weight for at least 18 months, including the most recent six months. This patients records document that the panniculus hangs below the level of the pubis. The patient complains of a recurrent rash underneath her abdominal pannus, but there is a lack of report of appropriate medical treatment of the rash or of failure of appropriate medical treatment of the rash. Moreover, there is a lack of documentation of a functional problem related to the rash despite appropriate medical treatment. Based on the current evidence-based medical literature, the requested panniculectomy is not medically necessary for this patient. In addition, the available records do not support the medical necessity of the requested abdominoplasty for treatment of this patient. As reported by the ASPS, A cosmetic abdominoplasty is sometimes performed at the time of a functional panniculectomy or delayed pending completion of weight reduction. Abdominoplasty, typically performed for cosmetic purposes, involves the removal of excess skin and fat from the pubis to the umbilicus or above, and may include fascial plication of the rectus muscle diastasis and a neoumbilicoplasty. There is a lack of documentation that the requested abdominoplasty is medically necessary for this patient based on the available documentation. Moreover, the requested repair of diastasis recti is not medically necessary for this patient. Emanuelsson and colleagues stated that, Functional disability related to midline bulging of the abdominal wall is a common complaint in women after childbirth. Abdominal rectus diastasis (ARD) is a sequela of the expansion of the abdominal contents during pregnancy. Massive weight loss and/or congenital disproportion of the collagen III/I ratio may also result in ARD. The authors commented that they have not found any studies indicating whether ARD repair provides long-term relief of symptoms (e.g, pain) and improvement of function or improves abdominal wall muscle strength. Strigard and colleagues noted that conclusive studies on the relationship between subjective symptoms and the width of ARD are lacking. Overall, there is a lack of support that abdominal diastasis rectus repair corrects or materially improves a bodily function. For this patient, abdominoplasty would not address a functional deficit. Similarly, the requested abdominal diastasis rectus repair is not being recommended to improve function. Thus, the requested repair of diastasis recti is not medically necessary for 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. On review of this patients records, there is a lack of report of medical treatment of a rash under the panniculus or of failure of medical treatment of a rash under the panniculus. A functional defect requiring panniculectomy has not been adequately documented. There is a lack of report of a functional problem from diastasis recti or lax abdominal tissue. The patients appearance is consistent with gain and loss of weight and the requested procedures will not create a more than minimal improvement in the patients appearance. Therefore, the requested abdominoplasty, repair of diastasis recti, and panniculectomy are not reconstructive in nature for treatment of this patient. All told, the requested abdominoplasty, repair of diastasis recti, and panniculectomy are not medically necessary and 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.