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

An enrollee has requested authorization and coverage for a panniculectomy.According to the American Society of Plastic Surgeons, a panniculectomy involves the removal of hanging excess skin and fat in a transverse or vertical wedge but does not include muscle plication, neoumbilicoplasty or flap elevation. 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. Researchers noted that the criteria for treatment by panniculectomy are that the panniculus hangs below the level of the pubis, the medical records document that the panniculus causes chronic intertrigo that consistently recurs over three months while receiving appropriate medical therapy or remains refractory to appropriate medical therapy over a period of three months. The records and photographs demonstrate that this patients panniculus hangs below the level of the pubis. The patient complains of hidradenitis suppurativa of the groin area. The records do not document that the patient has hidradenitis suppurativa or intertrigo in the infrapannicular area. The medical information does not specify whether the abscesses were in the groin area or the infrapannicular area. The patient reports using Silvadene cream. However, the records do not include evidence of failure of appropriate medical treatment of an infrapannicular rash. The patient does not have a functional problem with an infrapannicular rash that has been demonstrated to be resistant to appropriate medical treatment. Based on the evidence-based literature, the 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; or (2) to create a normal appearance, to the extent possible. The patients abdominal pannus is not the result of a congenital defect, a developmental abnormality, trauma, infection, tumors or disease. The patients pannus does not constitute an abnormal structure of the body. It is 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. Moreover, there is no functional deficit documented to support the requested procedure as reconstructive. All told, 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 for treatment of the patients medical condition and that they are not reconstructive in nature. 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.