Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Excess Skin

Treatment: Procedure Code 15830

The insurer denied coverage for Procedure Code 15830

The denial is upheld 

This is a patient who desires a panniculectomy. The patient has a history of morbid obesity and is status post sleeve gastrectomy. Since surgery the patient has lost 150 pounds (max weight 340, current weight 189) and maintained a stable weight for over 6 months. The patient complains of excess skin of the chest and abdomen causing fungal rash requiring prescription treatment as well as that interferes with exercise such as running and swimming.  The patient had a partially buried penis with skin tears that have improved with topical steroid medication.  The patient additionally notes that they have an arthritic hip for which they are planning arthroplasty. Per the patient, their orthopedic surgeon recommended skin excision prior to procedure to reduce risk of infection. Photos show a patient with a Grade 1 pannus. There is mild erythema in the lateral pannus folds. Panniculectomy is planned. 

The requested procedure is not medically necessary.

The panniculectomy is not medically necessary.  The medical records do not provide documentation in the form of primary care physician (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. The patient's most recent medication list does not include any topical or systemic medications for rashes or excoriation. The skin tears from their partially buried penis have resolved with topical steroids and weight loss. According to the American Society of Plastic Surgeons guidelines, "Patients considered for panniculectomy should document the type and duration of symptoms/treatment for panniculitis and photographs should confirm the patient's medical condition." Supervised medical management for rashes is not documented in any of the progress notes. The patient has not required hospitalization or treatment with intravenous (IV) or oral antifungal or antibiotic medications.  The excess skin has not jeopardized health.  Physician supervised treatment is the simplest, safest and most cost-effective method of managing this patient's problems, and conservative treatment with appropriate hygiene and topical medications has a reasonable likelihood of correcting the condition. 

In a multiple regression analysis of postoperative complications after body-contouring surgery written by Parvizi et al. the authors found that the overall rate for major complications that required operative revision and/or antibiotics was 10.2% (percent). In addition, 41% had minor complications, such as seromas, hematomas, wound healing problems, and wound dehiscence. Therefore, conservative, non-operative treatment would be recommended, such as improved hygiene, topical creams or powders, and watchful waiting.  Surgical treatment 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.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for Procedure Code 15830 is not substantiated.