Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Intertrigo at the overlying abdominal pannus area and excessive skin folds on the thighs.

Treatment: Excision of excessive skin and subcutaneous tissue.

The insurer denied coverage for excision of excessive skin and subcutaneous tissue.

The denial is upheld. 

This is a female patient with a history of anemia, asthma, diverticulitis, hyperlipidemia, liver lesion, migraine, sleep apnea, morbid obesity, status post bariatric surgery who presented with intertrigo at the overlying abdominal pannus area and excessive skin folds on the thighs.  The patient's condition has been refractory to conservative treatment.  The request is for surgical management. 

Based on the review of the medical record and literature, panniculectomy and abdominoplasty are not considered medically necessary for this patient.  The medical records do not provide any documentation in the form of primary care provider (PCP) or dermatology progress notes that describe ongoing clinically significant dermatologic problems that have either 1) never responded to physician-directed topical therapy; or 2) despite initial response, have recurred and caused significant functional impairment. Supervised medical management for rashes is not documented in any of the progress notes.  The patient is not sick from her excess skin, and has not had ulcerations, panniculitis or sepsis from her infections.  A dermatologist has not evaluated this patient's rashes.  The patient has not required hospitalization or treatment with intravenous (IV) or oral antifungal or antibiotic medications.  The excess skin has not jeopardized this patient's health.  Physician-supervised treatment is the simplest and safest method of managing this patient's problems, and conservative treatment with appropriate hygiene and topical medications has a reasonable likelihood of correcting this patient's condition. 

In a multiple regression analysis of postoperative complications after body-contouring surgery written by Parvizi et al. (2015), the study found that the overall rate for major complications that required operative revision and/or antibiotics was 10.2%.  In addition, 41% had minor complications, such as seromas, hematomas, wound healing problems, and wound dehiscences.  Therefore, conservative, non-operative treatment would be recommended, such as improved hygiene, topical creams or powders, and watchful waiting.  Surgical lipectomy should be reserved for patients that have failed optimal medical management for intertrigo, which is not documented to be the case for this patient.  Summary treatment letters and member appeal testimonies in the absence of physician office note documentation of specific dates of treatments and medications prescribed do not provide sufficient documentation to confirm the failure of medically supervised care.  Thus, the requested surgical intervention is not considered medically necessary for this patient at this time.

The health plan acted reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for excision of excessive skin and subcutaneous tissue should be upheld.  The medical necessity is not substantiated.