Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Loose abdominal skin. 
Treatment: 15830 excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy. 

The insurer denied coverage for 15830 excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy. 

The denial is overturned. 

 This is an adult with a medical history of lipodystrophy, intertrigo, ventral hernias, and a recurrent flank hernia. She was involved in a motor vehicle accident and sustained a liver laceration which required an open laparotomy for internal bleeding. The patient also developed renal failure which required hemodialysis for several months following surgery. She developed a right flank hernia and multiple ventral hernias which were repaired with mesh. The right flank hernia recurred, with herniation of the colon through the defect, causing significant pain. A computed tomography (CT) of the abdomen and pelvis noted diffuse laxity/bulging and undulating contour of the ventral abdominal wall without focal defect and a recurrent right flank hernia containing right colon. The patient was referred to two hernia specialists, both of whom recommended repair of the recurrent flank hernia. The patient also developed an abdominal pannus and was referred to plastic surgery. He noted that the pannus "reaches the level of the mons" pubis and that the size of the pannus has made it difficult for her to maintain good hygiene, with chronic irritation, recurrent rash, and blisters. She was prescribed clotrimazole-betamethasone cream followed by clobetasol propionate for the rashes. It is stated that because of her chronic kidney disease she is prevented from attempting any oral antibiotics for the treatment of the chronic irritation. The patient's surgical team has recommended panniculectomy due to recurrent rashes with concurrent abdominal wall reconstruction. 

Panniculectomy is indicated if any one of the following criteria is met: 

A. Inability to maintain hygiene of the lower abdominal and genital area 
B. Non-healing ulceration under the pannus 
C. Chronic maceration of overhanging skin folds 
D. Recurrent skin infection under panniculus despite treatment for 12 weeks  
E. Severe lower back pain and other etiologies excluded. 

This patient has clinical documentation of inability to maintain hygiene of the lower abdominal and genital area and also chronic maceration of the overhanging skin folds. She has had recurrent skin infections under the panniculus despite treatment for more than one year. 

This patient has documentation of complications from the panniculus, including chronic intertrigo and skin irritation that has been persistent despite nonsurgical treatment for over a year. The pannus interferes with her activities of daily living and prohibits her from participating in her usual activities due to pain and a persistent unpleasant odor causing significant psychological distress. The patient's weight has remained stable for her adult life at around 134 pounds, and she has not had a bariatric procedure. 

This patient has met the criteria for medical necessity for panniculectomy as set forth by national guidelines, including InterQual and Milliman Care Guidelines. Medical necessity has also been established by the criteria as set forth by the health care plan's clinical guidelines. Concomitant panniculectomy and hernia repair has been established in current literature as a safe and effective procedure. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for 15830 excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy services is substantiated.