Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Excess skin on abdomen
Treatment: Panniculectomy and Lipectomy (codes: 15830, 15847, 15877)
The health plan denied Panniculectomy and Lipectomy (codes: 15830, 15847, 15877). The denial has been upheld.

The patient is an adult female. She presented to her surgeon's office for a consult for excess skin on her abdomen. The patient has been working on weight loss and has lost 100 pounds to date after diet and exercise. The patient develops multiple infections and intertrigo due to the moisture and infections under the skin. She has been at her current weight for a few years. She is suffering from multiple skin infections as well as cellulitis for the past 6 months with no help from antibiotics or steroids. She was prescribed Nystatin for the rashes and skin ulcerations. She develops cellulitis and Leukocytosis. Even after using powders, there is still an odor due to the moisture under the skin. Her primary care provider has also advised she take over the counter pain medication for the back pain. She goes to Pain Management due to the back pain being so severe, but this is not helping with the constant pain. Her skin has recently opened up with sores due to the moisture and heat. This is causing her functional deficits with her everyday activities. She has a hard time getting clothes to fit properly due to the excess fat in the abdominal area. The surgeon recommends a Fleur-de-Lis surgery for medical necessity.

The body contouring procedures are not medically necessary. The medical records do not provide documentation in the form of PCP (primary care provider) 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. Supervised medical management for rashes is not documented in any of the progress notes. The patient is not sick from her excess skin, and has not had ulcerations, panniculitis or sepsis from her infections. A dermatologist has not evaluated the rashes. The patient has not required hospitalization or treatment with IV (intravenous) or oral antifungal or antibiotic medications. The excess skin has not jeopardized health.

Physician supervised treatment is the simplest, safest and least intensive 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 dehiscences.

Therefore, conservative, non-operative treatment would be recommended, such as improved hygiene, topical creams or powders, and watchful waiting. Surgical lipectomy 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 patient 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.