Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Excess pannus. 
Treatment: Procedure code 15830, panniculectomy. 

The insurer denied coverage for the procedure code 15830, panniculectomy. 

The denial is overturned. 

This is a female patient with a history of morbid obesity and gastric bypass surgery. She presented to the Plastic Surgeon's office for a follow up visit for wetness and folliculitis due to the presence of excess pannus. The patient reported that Nystatin did not work and hydrocortisone only got rid of the itching. She noted that her rashes were worse and that there was erythema with bleeding in the axilla region. She has tried medications which did not work. There is also periumbilical area tenderness. There were severe skin changes and irritation in the suprapubic area with bleeding and ulceration. There was hyperemia, skin breakdown, pigmentation changes, and irritation. The patient had severe intertrigo. The physician recommended following up with a dermatologist and having a panniculectomy to treat symptoms. 

According to the American Society of Plastic Surgeons Position Paper- Treatment of Skin Redundancy for Obese and Massive Weight Loss Patients, "When surgery to remove extensive skin redundancy and fat folds is performed solely to enhance a patient's 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 situations where a circumferential treatment approach is utilized to also treat the residual back and hip rolls or the ptotic buttock tissue, only the anterior portion of the procedures would be considered reconstructive, the remaining portion of the procedure would be considered cosmetic. 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 records indicate that the patient has failed conservative treatment for her longstanding rashes, including treatment by her surgeon over several months. Photos show rashes and skin breakdown under the pannus fold. A panniculectomy will eliminate her rashes. 

The patient's condition also meets the InterQual guidelines for a panniculectomy. 

The patient has chronic maceration, recurrent skin infections and an inability to maintain hygiene of the lower abdominal and genital areas. She has been treated for months with over the counter and prescription topical medications. 

The patient's condition also meets the Milliman Care Guidelines, 25th Edition for panniculectomy. 

The patient has persistent rashes despite medical treatment including prescription topical medications. The records confirm problems with activities of daily living. She has missed work due to her rashes. Photos show a heavy pannus with excoriations and rashes under the pannus. Her weight is stable based on the clinical notes. 

The health plan did not act reasonably. The panniculectomy is medically necessary. 

The insurer's denial of coverage for the procedure code 15830, panniculectomy is overturned. Medical necessity is substantiated.