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

Nature of Statutory Criteria/Case Summary: The patient is a male with a history of heart failure, advanced renal failure, hypertension, diabetes, and pulmonary embolism for which he is anticoagulated. At baseline, he is mostly bedridden and ambulates only when necessary. On 12/4/17, he was 5 feet 11 inches and weighed 474 pounds with a body mass index (BMI) of 66.1. On 12/5/17, the provider noted the patient has an enormous pannus. He is unable to independently transfer to a walker from bed or walk 50 feet. Photos were not received for review. The patient has requested authorization and coverage for a panniculectomy. The Health Plan has denied the requested procedure as not medically necessary.In a medical literature noted that panniculectomy is an elective procedure where medical problems must be under control before the operation. Surgery should be avoided in any patient with an uncontrolled cardiac disease, lung disease, or diabetes.  higher BMI was demonstrated to be intimately associated with increased risk of complications. Having a BMI over 26 trended toward significance as an independent predictor of morbidity. This patient has a measured weight loss of more than 100 pounds. However, he remains morbidly obese with a body weight of 368 pounds and a BMI of 51.3. In addition, documentation of serial weights demonstrates that he is currently undergoing progressive weight loss, and his weight loss has not stabilized. The medical records document disability from morbid obesity with restrictions in activities of daily living, including walking, bathing, restroom necessities, sleeping and dressing. Thus, the records do not support that he would have significant functional improvement from a panniculectomy. He remains a serious operative risk for postoperative morbidity, with serious cardiac and renal failure as well as a history of pulmonary embolism. For these reasons, the requested panniculectomy is not medically necessary for treatment of this patients medical condition. Moreover, the requested panniculectomy is not reconstructive in nature under the California law, which 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 patients case, an abdominal pannus is not the result of a congenital defect, a developmental abnormality, trauma, infection, tumor or disease. The pannus is not an abnormal structure of the body, rather a normal structural change that is an accommodative response to gain or loss of body mass. The appearance of the patients pannus is normal and consistent with the gain and loss of weight. Further, the requested surgery will not improve the patients level of function. The records note that his restrictions on mobility are not due to the presence of excess skin. Furthermore, the requested procedure will not offer a more than minimal improvement in the patients appearance based on the documented reviewed. Thus, the requested service does not qualify as reconstructive surgery under the California law.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. 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.