Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Skin infection.
Treatment: Panniculectomy (procedure code 15830).
The insurer denied coverage for panniculectomy (procedure code 15830). 
The denial is overturned.

A panniculectomy (15830) is medically necessary. According to the American Society of Plastic Surgeons (ASPS) Position Paper "Treatment of Skin Redundancy for Obese and Massive Weight Loss Patients", "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 and not a compensable procedure. For example, a panniculectomy to eliminate a large hanging abdominal panniculus and its associated symptoms would be considered reconstructive. 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." The records indicate that the patient has failed conservative treatment for his rashes, including treatment by her PCP (primary care physician) and dermatologist. Photos show rashes under the pannus fold. A panniculectomy will eliminate her rashes. The patient's condition also meets the InterQual guidelines for a panniculectomy. According to the InterQual guidelines, panniculectomy is medically necessary if any one of the following guidelines are met: 1) Inability to maintain hygiene of the lower abdominal and genital area, 2) Non-healing ulceration under the pannus, 3) Chronic maceration of overhanging skin folds, 4) Recurrent skin infection under panniculus despite treatment for 12 weeks, or 5) Severe lower back pain and other etiologies excluded.

The patient has chronic maceration, recurrent skin infections and an inability to maintain hygiene of the lower abdominal and genital areas. He has been treated for months with over the counter and prescription topical medications. 

Finally, the patient's condition meets the Milliman Care Guidelines (MCG), 25th Edition for panniculectomy. Per the guidelines:

Panniculectomy may be indicated when ALL of the following are present: 1) Patient has complications from panniculus (eg, chronic or recurrent intertrigo, other skin infection, ulceration, or skin irritation that has been persistent despite nonsurgical treatment), 2) Pannus interferes with activities of daily living, and 3) Patient's weight has reached stable plateau, and 1 or more of the following: 1) Adherence to multidisciplinary nonsurgical program of weight maintenance, or 2) One year or more has elapsed following bariatric surgery.

The patient has persistent rashes despite medical treatment including prescription topical medications from his dermatologist. The records confirm problems with activities of daily living. Photos show a heavy pannus with excoriations and rashes under the pannus. Her weight is stable based on the clinical notes. 

Based on the ASPS, MCG, and InterQual guidelines, a panniculectomy is medically necessary for this patient.

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for surgical procedure (procedure code 15830) is overturned. Medical Necessity is substantiated.