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. Findings:  The physician reviewer found that according to the American Society of Plastic Surgeons (ASPS), panniculectomy involves the removal of hanging excess skin and fat in a transverse or vertical wedge but does not include muscle plication, neoumbilicoplasty or flap elevation. A Panniculectomy is a noncosmetic procedure typically performed to assist in the correction of a functional impairment. The ASPS states that Patients considered for panniculectomy should document the type and duration of symptoms and treatment for panniculitis. Documented recalcitrant panniculitis may be considered as indication for panniculectomy. Photographs should confirm the patients medical condition. Patients considered for panniculectomy should document specialist (back) evaluation, radiological evaluation and duration of symptoms and treatment for chronic back pain felt related to their panniculus. Direct correlation is recommended before panniculectomy is considered. Photographs should confirm the patients medical condition. Improvement in a patients activities of daily living should not be considered as an indication for panniculectomy.In this case, the patient had gastric sleeve surgery following which she lost approximately 110 pounds. The patient has had an abdominal pannus and complained of associated, persistent and recurrent rash and intertrigo that is documented in medical records dating back two years. Conservative treatment with antifungal cream has not provided relief. Records also reflect associated low back pain and a history of treatment for back spasms. The submitted documentation also includes photographic confirmation of the patients medical condition. Under these circumstances, the requested panniculectomy is medically necessary to treat the patients medical condition.The California reconstructive surgery statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function; or (2) to create a normal appearance, to the extent possible. In this case, the patient has an abdominal pannus, which is an expected appearance given the patient's weight and BMI. The alleged abnormality therefore does not constitute an abnormal structure of the body. Accordingly, the requested panniculectomy is not reconstructive in nature for treatment of this patient.Final Result: The reviewer determined that the requested services are medically necessary to treat the patient's 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.