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

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for infraumbilical panniculectomy, excision excessive skin and tissue abdomen, and suction assisted lipectomy trunk for treatment of the enrollees panniculitis.  Findings:  The physician reviewer found that the patient presents with evidence of chronic intertrigo related to an overlapping abdominal pannus that has failed conservative management with creams and lotions. In addition, she is noted to have periodic painful, skin breakdowns underneath her lower abdominal pannus.  Thus, the patient has evidence of functional impairment with chronic rashes unresponsive to reasonable conservative dermatologic management.  The medical documentation, including review of the photographs, supports that the likely primary source for this functional deficit is the lower abdominal pannus. The lower abdominal pannus is overlapping and previous documentation had noted active rashes that support this functional impairment. Based on the medical documentation and photographs provided, the lower abdomen is well supported to be the source of functional problems. A lower abdominal panniculectomy is indicated to correct a functional problem of significant intertrigo and skin breakdown. Therefore, the request for infraumbilical panniculectomy is medically necessary and reconstructive in nature for treatment of the patients medical condition.  However, there is a lack of evidence demonstrating a functional problem with the upper abdominal pannus. Thus, liposuction is not indicated in this case. According to the American Society of Plastic Surgeons (ASPS), In situations where a circumferential treatment approach is utilized to also treat the residual back and hip rolls or the ptotic buttock tissue, only the anterior portion of the procedures would be considered reconstructive, the remaining portion of the procedure would be considered cosmetic. Only in rare circumstances will buttock, thigh or arm lifts be needed to treat functional abnormalities. Typically these procedures are performed to improve appearance and are therefore cosmetic in nature. Support for functional correction with upper abdominal panniculectomy and liposuction has not been provided in the records reviewed. In regards to the reconstructive in nature criteria, the request for excision excessive skin and SubQ tissue abdomen, and suction lipectomy trunk is not reconstructive in nature for treatment of the patients medical condition. The patients condition does not constitute an abnormal structure of the body. The upper abdomen and areas that would be treated with lipodystrophy are not abnormal. The proposed services would not improve function or create a normal appearance. The upper abdomen and areas of lipodystrophy not treated with a lower panniculectomy are normal based on the patients size and body habitus. Moreover, there is no evidence to support that the planned procedures would restore symmetry. The requested surgery would not likely provide a more than minimal improvement. Final Result: The reviewer determined that a portion of the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially 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.