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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for panniculectomy. According to the American Society of Plastic Surgeons (ASPS), a panniculectomy involves the removal of hanging excess skin and 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 patients appearance in the absence of any signs or symptoms of functional abnormalities, the procedure should be considered cosmetic in nature. Medical literature states that the criteria for treatment by panniculectomy include a panniculus that hangs below the level of the pubis and documentation that the panniculus causes chronic intertrigo that consistently recurs over three months while receiving appropriate medical therapy or remains refractory to appropriate medical therapy over a period of three months. The patient underwent a gastric sleeve procedure in the past. She is presently 190 pounds. She has abdominal obesity, and the abdominal pannus hangs below the level of the pubis. She presents with severe lower abdominal pain. Loose skin in the form of an abdominal pannus is not a source of abdominal pain or pelvic pain. A panniculectomy is not medically necessary for relief of abdominal pain or pelvic pain. The patient complains of a recurrent rash underneath her abdominal pannus, but there the records do not establish that the patient has failed appropriate medical treatment of the rash. The provider recommended treatment with Nystatin and clotrimazole. Subsequent records do not support the presence of a recurrent rash that has not responded to standard therapies. The patient does not have a functional problem with the rash that has been demonstrated to be resistant to appropriate medical treatment. Based on the current evidence-based literature, the requested panniculectomy is not medically necessary for this patient. 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. Based on the available documentation, this patient does not have a functional issue related to her abdominal pannus. Thus, the requested procedure will not address a functional impairment. In addition, an abdominal pannus is not a result of a congenital defect, developmental abnormality, trauma, infection, tumor, or disease. The patients abdominal pannus is not an abnormal structure of the body, rather it is a normal structural change that is an accommodative response to the loss of body mass. The appearance of the patient is normal and consistent with the gain and loss of weight. For these reasons, the requested panniculectomy is not reconstructive in nature for treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary and not reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer 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.