Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Excess skin after weight loss

Treatment: Panniculectomy

The insurer denied coverage for panniculectomy.

The denial is upheld.

The medical records do not provide documentation in the form of primary care physician (PCP) 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. According to the American Society of Plastic Surgeons guidelines, "Patients considered for panniculectomy should document the type and duration of symptoms/treatment for panniculitis and photographs should confirm the patient's medical condition." 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 intravenous (IV) or oral antifungal or antibiotic medications.  The excess skin has not jeopardized health.  Physician supervised treatment is the simplest, safest and most cost-effective 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%. In addition, 41% had minor complications, such as seromas, hematomas, wound healing problems, and wound dehiscence. 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 member 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.

Although the patient's surgeon and PCP have submitted letters of attestation describing the failure of medical care, summary treatment letters and member appeal testimonies; in the absence of physician office note documentation of specific dates of treatments and medications prescribed there is not sufficient documentation to confirm the failure of medically supervised care.  The patient should submit office note documentation that she has failed medical management for rashes such that surgery is the only alternative for management of her skin condition.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for ambulatory surgery outpatient procedure (15830 x 1) is not substantiated.