Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Abdominal Pannus and Rashes.
Treatment:  Panniculectomy and bilateral hip lipectomy.

The insurer denied the Panniculectomy and bilateral hip lipectomy.  The determination is upheld.

The patient has complaints of an abdominal pannus and rashes after weight loss.  He had bariatric surgery and lost 74 pounds (lbs). His weight was stable for 12 months.  He also complains of back pain, hygiene issues, and odor.  Conservative treatment includes: oral antibiotics, antifungal creams, Diflucan, Miconazole, ketoconazole, Mycostatin powder, chiropractic care.  His last recorded weight was 162 lbs, body mass index (BMI) 27.  The exam findings were reviewed and noted.  The surgeon has requested a panniculectomy/hip lipectomy (lower body lift).  The photographs were reviewed. At issue is the medical necessity of a panniculectomy and bilateral hip lipectomy.  
The requested panniculectomy and bilateral hip lipectomy are not medically necessary for this patient.  The provided rationale applies to both codes, since the procedure planned is a lower body lift and this surgery is coded by 2 current procedural terminology (CPT) codes (panniculectomy [15830] and hip lipectomy [15834] lower body lift).  A panniculectomy is typically performed in patients after massive weight loss with a symptomatic abdominal pannus that is unresponsive to conservative measures.  According to the American Society of Plastic Surgeons (ASPS) guidelines, "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.  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."  In order to prove medical necessity, chronic maceration of skin folds with failure to respond to medical therapy, difficulty with ambulation, interference with activities of daily living (ADLs), and a hanging pannus below the pubis are frequently required to be demonstrated (Dreifuss et al.). According to ASPS 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."  Confirmatory evidence of symptoms, such as a history of conservative therapy, photographic evidence of symptomatic, excess abdominal skin and a history of frequent primary care physician visits for abdominal pannus-caused symptoms is necessary to support the history provided by the plastic surgeon.  Other than the history of symptoms provided by the patient to the plastic surgeon, the objective documentation does not support a need for a medically necessary panniculectomy.  There does not appear to be a convincing correlation between the clinical complaints documented and the external photos submitted.  The pannus does not appear to clearly hang below the mons pubis, and active inflammatory skin conditions are not demonstrated in the attached photographs.

Panniculectomy is a surgery that has a relatively high rate of wound related complications, approximately 27% according to Barbour et al.  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 dehiscences.  Also, the complication rate for body-contouring procedures is much higher (60-87% increased) in the post bariatric surgery population, as compared to patients who lost weight due to diet and exercise (Hasanbegovic et al.).

Since the perioperative risks of surgery are relatively high, surgical management in the form of a panniculectomy is reserved for patients who have exhausted and failed all conservative medical management options for unresponsive intertrigo, rashes, cellulitis, skin necrosis, and ulcerations, or have a long pannus which interferes with ambulation, which has not been demonstrated in this patient.

For the aforementioned reasons, the requested panniculectomy and bilateral hip lipectomy are not medically necessary.