Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Excess Skin Resulting in Breakdown and Infections. 
Treatment: Panniculectomy. 
The insurer denied coverage for panniculectomy. 
The denial is upheld. 

This patient has lost a total of 110 pounds (lbs.) and their weight has been stable for 2 years. The patient complains of excess skin and tissue inhibiting daily function and rashes and irritation that are unresponsive to creams and powders. Additionally, the patient notes overall dysphoria regarding hanging skin. 

The skin issues including rashes, breakdown, and pain inhibit their activities of daily living (ADLs) including exercise, heavy lifting, and care. The patient has tried creams/powders/ garments for 3 years and has not had any improvement in symptoms. The patient has been under the care of a dermatologist and bariatric surgeon to help with these issues and has had no improvement in symptoms. The patient also has a hernia that has protruded into their lower pannus resulting in thinning skin and significant deformity. The patient also has a hypertrophic scar in their mid-abdomen that causes them pain and restriction in movement. 

Medical necessity for panniculectomy is not established. The patient has had multiple prior abdominal surgeries and is at an increased risk for complications with abdominoplasty surgery. Therefore, surgery should be undertaken only when medical therapy has failed. 

The panniculectomy is not medically necessary. 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 their excess skin and has not had ulcerations, panniculitis, or sepsis from their 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 who 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. 

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 panniculectomy is not substantiated.