Appeal type: Medical necessity
Decision: Overturned

Diagnosis: s/p Bariatric surgery. 
Treatment: Panniculectomy, Pre-service. 

The insurer denied the Panniculectomy, Pre-service. 
The denial is overturned. 

The patient is a female. She has lost over 100 pounds following bariatric surgery.  Her weight has been stable for three years. She has generalized skin laxity, and she complains of rashes in the folds under her pannus and inner thighs. She treats the rashes with anti-fungal medications. Panniculectomy is planned. 

Yes, the panniculectomy is medically necessary. 

A panniculectomy (15830) is medically necessary.  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 PCP (primary care provider). 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. According to the InterQual guidelines, panniculectomy is medically necessary if any one of the following guidelines are met: 
1) Inability to maintain hygiene of the lower abdominal and genital area
2) Non-healing ulceration under the pannus 
3) Chronic maceration of overhanging skin folds 
4) Recurrent skin infection under panniculus despite treatment for 12 weeks 
5) Severe lower back pain and other etiologies excluded 

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. 

Finally, the patient's condition meets the Milliman Care Guidelines, 25th Edition for panniculectomy. Per the guidelines: 

Panniculectomy may be indicated when ALL of the following are present: 1) Patient has complications from panniculus (eg, chronic or recurrent intertrigo, other skin infection, ulceration, or skin irritation that has been persistent despite nonsurgical treatment). 
2) Pannus interferes with activities of daily living. 
3) Patient's weight has reached stable plateau, and 1 or more of the following: 
a) Adherence to multidisciplinary nonsurgical program of weight maintenance
b) One year or more has elapsed following bariatric surgery 

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. 

Based on the ASPS (American Society of Plastic Surgeons), MCG (Milliman Care Guidelines), and InterQual guidelines, a panniculectomy is medically necessary for this patient. 

This patient has had chronic rashes, and medical treatments with topical anti-fungal creams have not improved her symptoms. Panniculectomy is medically necessary.