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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for abdominal lipectomy/panniculectomy.Findings:  The physician reviewer found that abdominal panniculectomy (CPT 15830 excision of excessive skin abdomen), according to the American Society of Plastic Surgeons (ASPS), a panniculectomy involves the removal of hanging excess skin/fat in a transverse or vertical wedge but does not include muscle plication, neoumbilicoplasty or flap elevation. Sachs and colleagues state, A panniculectomy must meet specific criteria to be medically necessary. The pannus must hang below the level of the pubis and be confirmed with photography. Patients must fail medical treatment of intertrigo for three months. Medical treatment includes good hygiene, topical antifungals, corticosteroids, and antibiotics. The role of panniculectomy is to restore normal function. Patients must maintain a stable weight for at least six months. After bariatric surgery, patients must maintain a stable weight for at least 18 months, including the most recent six months. In this case, the patient is status gastric bypass and a Lap-Band with revision. The records noted weight loss from 365 pounds to her current weight of 235 pounds with a BMI of 37.93 kg/m2. Photographs showed abdominal obesity with a pannus that hangs below the symphysis pubis. The records noted that the patients medications included phentermine for weight loss. While the patient reported intertrigo and boils, a physical examination did not report intertrigo. The records did not document appropriate medical treatment of a rash or the 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. Therefore, abdominal panniculectomy (excision of excessive skin abdomen) is not medically necessary for the treatment of this patient.Regarding abdominal lipectomy/panniculectomy (excision of excessive skin abdomen add on), according to the ASPS, a cosmetic abdominoplasty is sometimes performed at the time of a functional panniculectomy or delayed pending completion of weight reduction. Abdominoplasty, typically performed for cosmetic purposes, involves the removal of excess skin and fat from the pubis to the umbilicus or above, and may include fascial plication of the rectus muscle diastasis and a neoumbilicoplasty. When surgery to remove extensive skin redundancy and fat folds is performed solely to enhance a patient's appearance in the absence of any signs or symptoms of functional abnormalities, the procedure should be considered cosmetic in nature. The ASPS further notes that one code, for panniculectomy, may be billed to insurance when appropriate, while the other code, for abdominoplasty, describes a cosmetic procedure. Therefore, abdominal lipectomy/panniculectomy (excision of excessive skin abdomen add on) is not medically necessary for the treatment of this patient.Regarding abdominal lipectomy (suction lipectomy trunk), in this case, the patient has severe abdominal obesity. The records do not document a specific functional disability. Therefore, abdominal lipectomy (suction lipectomy trunk) is not medically necessary to treat the patients medical condition. The California reconstructive surgery statute requires health insurers 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: (1) to improve function; (2) to create a normal appearance, to the extent possible. In this case, the patient has exogenous obesity with an abdominal pannus. The records do not document intractable intertrigo. Exogenous obesity is not an abnormal structure of the body, and it is not caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease. Therefore, abdominal lipectomy/panniculectomy (excision of excessive skin abdomen; excision of excessive skin abdomen add on; suction lipectomy trunk) is not reconstructive in nature for the treatment of this patient.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition and are not reconstructive in nature. 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.