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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for panniculectomy excision of excessive skin and subsequent tissue of the buttock tissue grafts and suction-assisted lipectomy of the trunk The submitted documentation fails to demonstrate the medical necessity of the requested panniculectomy .There is no photographic documentation of a panniculus or a report of a panniculus on physical examination. Findings:  The physician reviewer found that there is also no complaint of a recurrent rash beneath an abdominal panniculus or of failure of treatment of such a rash. Under these circumstances, the medical information received for review does not support that a panniculectomy is medically necessary. Additionally, there is no functional loss that is documented to be related to an abdominal pannus. The submitted photographs also do not establish that the appearance of the patients abdomen is outside the wide range of normal. Thus, there is no demonstration that the requested panniculectomy would be performed to either improve function or create a normal appearance, and it is therefore not reconstructive in nature.With regard to the requested excision of excessive skin and subsequent tissue of the buttock15835), no photographs of the patients buttocks area were submitted for review. There is also no report of lax buttocks skin similar to an abdominal panniculus. There is no report of symptomatic lax buttocks skin reported on physical examination. There is no complaint of a recurrent rash beneath excess buttocks skin or of failure of treatment of such a rash. Based on the medical information received for review, the requested excision of excessive skin and subsequent tissue of the buttock is not medically necessary. Additionally, no functional loss is documented to be related to excessive skin of the buttock. There was also no photographic documentation submitted to establish that the appearance of the buttocks was outside the wide range of normal. As a result, there is no demonstration that the requested excision of excessive skin and subsequent tissue of the buttock would be performed to either improve function or create a normal appearance, and it is therefore not reconstructive in nature.The requested tissue grafts would be performed to accomplish a transfer of fat to the patients buttocks. Guzman states that HIV-associated lipodystrophy is an undesirable effect of anti-retroviral therapy (ART) that occurs due to the redistribution of adipose tissue. Guzman explains that HIV-associated lipodystrophy includes both fat accumulation (lipohypertrophy) and fat loss (lipoatrophy) or both. Lipoatrophy occurs on the face, the buttocks, the arms, and the legs, whereas lipohypertrophy occurs in the truncal areas and manifests as abdominal obesity, mammary hypertrophy, accumulation of fat on the neck or lipomas. Guzman states that on physical exam, the clinician should evaluate for features of lipoatrophy as manifested by loss of peripheral fat tissue noticed in the upper, lower extremities and buttocks as well as malar and temporal areas. Extremities appear thin with the prominence of superficial veins, and loss of facial fat causes sunken eyes and cachectic facial features. Glesby states that patients with lipoatrophy have loss of subcutaneous fat, most noticeably in the limbs, face, and/or buttocks areas. Patients with fat accumulation have gain of visceral fat in the abdomen and may have dorsocervical fat pad enlargement (buffalo hump) and breast enlargement. In this case, while HIV associated lipoatrophy of the buttocks has been reported, no photos were submitted for review to document lipoatrophy of the buttocks. Furthermore, no medical record documentation of HIV associated lipoatrophy of the buttocks was received for review. Based on the medical information received for review, tissue grafts (CPT 20926) are not medically necessary. In addition, no functional loss is claimed or documented other than discomfort while sitting that was outside the wide range of Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition and 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.