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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for panniculectomy or treatment of the enrollees large pannus. Findings:  The physician reviewer found that The request for panniculectomy is medically necessary for treatment of the patients medical condition. The patient presents with a severely enlarged abdominal pannus and has been recommended for a panniculectomy as a combined procedure with TAH/BSO. The combined procedure allows for greater access to the pelvis and may help prevent lower incisional maceration. The combined procedure of panniculectomy with TAH/BSO is supported as beneficial in the medical literature. On morbidly obese patients, the pannus will remain an obstacle during gynecologic surgery, which requires additional instrumentation or personnel to help retract it, to obtain proper exposure. There is also the need for much longer instruments, which might not be readily available and delay the procedure. In addition, performing a panniculectomy decreases the incidence of wound issues, because most morbidly obese women are unable to maintain proper hygiene of the lower abdominal area and develop chronic maceration and intertrigo under the overhanging skin fold. With respect to possible increased infection risk due to the combined procedure, the authors state that The data indicate that there is no significant difference in complications between those who chose to undergo a combined panniculectomy and hysterectomy compared to hysterectomy alone. Thus, the requested panniculectomy has been established as medically necessary for treatment of the patients severely enlarged abdominal pannus. The requested panniculectomy is reconstructive in nature for treatment of the patients medical condition. In this case, the patient has a severely abnormal abdominal pannus and panniculectomy may help to provide adequate access for the hysterectomy and prevent wound breakdown. The patients medical condition constitutes an abnormal structure of the body as there is documentation supporting a severely enlarged abdominal pannus. The abnormal structure of the body is the result of obesity, which is a disease. The requested surgery is being performed to improve function to provide greater access to the pelvis for the gynecologic procedure which is expected to lead to increased efficiency of the gynecologic procedure and help to prevent maceration and wound healing issues. The proposed surgery is expected to create a normal appearance to the extent possible and offer more than a minimal improvement. For the reasons provided, the requested surgery is medically necessary and reconstructive in nature for treatment of the patients medical condition. inal Result: The reviewer determined that the requested surgery is medically necessary and reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. 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.