Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Intertrigo

Treatment: Procedure code 15830 for the excision of excessive skin and subcutaneous tissue (including lipectomy); abdomen, infraumbilical panniculectomy

The insurer denied coverage for procedure code 15830 for the excision of excessive skin and subcutaneous tissue (including lipectomy); abdomen, infraumbilical panniculectomy. The denial is upheld.

This patient is a female with a past medical history significant gastrointestinal problems for many years. She underwent placement of a gastric pacemaker and then subsequently underwent a laparoscopic colectomy with ileorectal anastomosis. The patient was able to lose significant weight after having normal gastrointestinal motility. She is experiencing ongoing issues with rashes and pain after losing weight. She complained of back, neck, and shoulder pain due to her breasts. The patient is reported to have episodes of intertrigo in the abdominal fold, treated with Nystatin. Panniculectomy was requested.

The patient complains of rashes, but the medical records do not provide any 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 medical issues. Supervised medical management for rashes is not documented in any of the progress notes. The patient is not sick from her excess skin, and has not had ulcerations, panniculitis or sepsis from her infections.  A dermatologist has not evaluated the rashes.  The patient has not required hospitalization or treatment with IV or oral antifungal or antibiotic medications.  The excess skin has not jeopardized health.  

Physician supervised treatment is the simplest, and safest 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 post-operative 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. 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 that 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.  

The health plan acted reasonably with sound medial judgment in the best interest of the patient.

Based on the above, the medical necessity for procedure code 15830 for the excision of excessive skin and subcutaneous tissue (including lipectomy); abdomen, infraumbilical panniculectomy is not substantiated.  The insurer's denial is upheld.