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

A 54-year-old female has requested abdominal wall reconstruction/panniculectomy, hernia repair (CPT 49560), breast tissue reconstruction/mastopexy (CPT 19319), and excessive skin removal/whole body lift (CPT 15831 for treatment of her medical condition status post gastric bypass with weight loss.  Findings:  The physician reviewer found that the excess abdominal tissue of the lower abdomen and ptotic breast tissue should be considered abnormal as a result of obesity and subsequent weight loss. This finding is consistent with the photographs and medical documentation as obesity can be considered a disease. Obesity correction is known to create significant functional deficits as documented in the references. The patient does complain of difficulties with her overlapping tissue of the breasts and abdomen. She reports irritation, rashes and open sores and has tried over-the-counter medications. The documentation from the surgeon and primary care physician as well as analysis of the photographs supports a functional deficit of the lower abdomen mainly. The surgeon reports some of the complaints of the patient, but does not describe in the examination a full account of changes in the breasts that would likely explain the patients complaints. Further, there was no mention of chronic changes or intertrigo of the breasts. A detailed report of attempted treatments and their success or failure is lacking. The American Society of Plastic Surgeons (ASPS) has addressed treatment following massive weight loss. The ASPS states and defines the difference between reconstructive and cosmetic surgery and noted 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. For example, a panniculectomy to eliminate a large hanging abdominal panniculus and its associated symptoms would be considered reconstructive. In addition, they stated that, only in rare circumstances will buttock, thigh or arm lifts be needed to treat functional abnormalities. Typically these procedures are performed to improve appearance and are therefore cosmetic in nature. The photographs of the patients lower abdomen show significant overlap, which could be consistent with the complaints of the patient. Overall, the records do not document a functional deficit for the breasts, but do explain a functional deficit related to the lower abdomen. By contrast, an abdominoplasty with muscle plication is rarely for functional issues and a diastasis rectus is not a true hernia. The patient does have an abnormal appearance of the breasts and lower abdomen. The photographs confirm the abnormal appearance of the lower abdomen. The upper abdomen does not appear to be as significant. All told, the requested panniculectomy would be expected to offer more than a minimal improvement. The photographs confirm the assertions by the patient, primary care physician, and surgeon. Finally, the appearance of the breasts confirms a grade II ptosis, but does not appear to be significantly abnormal to justify treatment and may be expected given her age and current weight. However, an abdominoplasty or lower body lift treating the upper abdomen does not appear to be a significant source of the appearance related issues. Muscle plication for diastasis rectus is not treatment of a true hernia, and thus hernia repair should not be considered as a compensable procedure based on the definition of a ventral hernia repair. With respect to the breasts, based on the photographs the level of ptosis present is not significant enough to adequately support that more than a minimal improvement in the appearance is expected. The medical records do not further define a significantly abnormal appearance different from what is visualized in the photographs. In summary, the requested panniculectomy should be authorized as reconstructive in nature and medically necessary. A panniculectomy could be considered part of abdominoplasty or a lower body lift, as the part that should be authorized. However, the ventral hernia repair, lower body lift, abdominoplasty, or mastopexy, should not be authorized as these services are not supported as reconstructive in nature or medically necessary.