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 (CPT code 15830) and buttocks lift (CPT code 15835). The submitted documentation supports the medical necessity of a portion of the requested services. The records document functional impairment with chronic rashes, and he has failed treatment with antifungal medications and proper hygiene. Although the photographs only show evidence of a moderate condition anteriorly, the history and physical examination support chronic rashes. The requested panniculectomy is likely to significantly improve his functional impairment and is medically necessary for the treatment of this patient. The patient has chronic rashes associated with excess abdominal tissue as the result of massive weight loss. His condition constitutes an abnormal structure of the body. The lower abdominal pannus is an excess overlapping collection of tissue that is considered abnormal. This abnormal structure of the body is caused by the disease of obesity. Treatment of his obesity has led to an excess skin overlap of the abdomen. The requested panniculectomy is likely to both improve the functional impairment associated with chronic rashes as well create a more normal appearance. Additionally, the requested panniculectomy would provide more than a minimal improvement in the appearance of this patient. Thus, the requested panniculectomy (CPT code 15830) is medically necessary and is reconstructive in nature.The medical records fail to demonstrate the medical necessity of the requested buttocks lift (CPT code 15835). The medical documentation supports that the functional impairment is associated with the anterior lower abdomen, not the back. Per the records, it is not clear if the patient has chronic rashes of the back and buttocks. In addition, the degree of excess of the buttocks and lower back is minimal to mild and would not likely lead to significant skin to skin contact to produce rashes. In this case, the patients condition constitutes an abnormal structure of the body. Minimal to mild excess of the back and buttocks would be an abnormal collection of soft tissue. This abnormal structure of the body is caused by the disease of obesity. Treatment of this patients obesity has led to an excess skin overlap of the abdomen.  However, the requested buttocks lift is not likely to either improve function or create a normal appearance to the extent possible. There is insufficient documentation to support that a functional improvement would be likely. Additionally, the requested buttocks lift would not provide more than a minimal improvement in the appearance of this patient. Therefore, the requested buttocks lift (CPT code 15835) is not medically necessary and is not reconstructive in nature. Final Result: The reviewer determined that a portion of the requested services is 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.