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

The patient has requested authorization and coverage for abdominal panniculectomy. At issue in this case is whether the requested panniculectomy is medically necessary for treatment of the patients medical condition. In addition, does the patients condition constitute an abnormal structure of the body? If so, is the abnormal structure of the body caused by any of the following: congenital abnormalities; developmental abnormalities; trauma; infection; tumors or disease? If so, is the requested surgery performed to do either of the following: improve function or create a normal appearance to the extent possible? If so, does the surgery provide more than a minimal improvement in the appearance of the patient?According to the American Society of Plastic Surgeons (ASPS), a 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. When surgery to remove extensive skin redundancy and fat folds is performed solely to enhance a patients appearance in the absence of any signs or symptoms of functional abnormalities, the procedure is not supported as reconstructive. The current accepted criteria for treatment by panniculectomy include documentation that the pannus hangs below the level of the pubis, and that the panniculus causes chronic intertrigo that consistently recurs over three months while receiving appropriate medical therapy or remains refractory to appropriate medical therapy over a period of three months. Photographs document that this patients pannus hangs below the level of the pubis. The patient complains of a recurrent rash underneath her abdominal pannus, but there is no report of appropriate medical treatment of a rash or of failure of appropriate medical treatment of a rash. The patient does not have a functional problem with a rash that has been demonstrated to be resistant to appropriate medical treatment. In addition, photographs of the area below the abdominal pannus do not demonstrate a rash or evidence of current skin irritation. The patient also reports that she was diagnosed with meralgia paresthetica. However, there is no report of medical treatment or documentation that the condition is the result of her abdominal pannus. Colleagues noted that, meralgia paresthetica is an entrapment neuropathy of the lateral femoral cutaneous nerve that may cause paresthesias, pain, and sensory loss of the anterior and lateral thigh. Treatment is primarily medical. Surgery is an option for patients who do not respond to medical treatments. Based on the evidence-based literature, an abdominal panniculectomy is not medically necessary.The California Reconstructive Surgery Statute requires Health Plans 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: to improve function; or to create a normal appearance, to the extent possible. An abdominal pannus is not a result of a congenital defect, a developmental abnormality, trauma, infection, tumor or disease. An abdominal pannus is not an abnormal structure of the body, rather it is a normal structural change that is an accommodative response to gain or loss of body mass. The appearance of the patient is normal and consistent with the gain and loss of weight. A functional problem with an intractable rash has not been demonstrated. Therefore, the requested abdominal panniculectomy is not reconstructive in nature for this patient. Final Result: The reviewer determined that the requested services are not medically necessary and are not reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. 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.