Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Redundant abdomen and atrophic disorder of the skin following beneficial weight loss.

Treatment: Abdominoplasty (code 15847) for the diagnosis of redundant abdomen and atrophic disorder of the skin following beneficial weight loss.

The insurer denied coverage for the abdominoplasty (code 15847) for the diagnosis of redundant abdomen and atrophic disorder of the skin following beneficial weight loss.

The denial is upheld. 

This is a female patient with a surgical history of bariatric surgery. Post-surgery, the patient had excess abdominal skin, abdominal cellulite, abdominal wall laxity and diastasis of the rectus muscle.  The patient was also noted to have a wide diastasis of the rectus abdominal muscle. The patient tried over-the-counter (OTC) pain medication and powder, but without relief.  The treatment plan included a full abdominoplasty, fascial plication and panniculectomy.  The patient underwent the surgical procedure for a massive panniculectomy and complex abdominoplasty.

Based on the review of the medical record and literature, abdominoplasty was not medically necessary for this patient.  The panniculectomy (already approved) was medically necessary, but the abdominoplasty is not medically necessary.  According to the American Society of Plastic Surgeons (ASPS) Position Paper on the treatment of skin redundancy for obese and massive weight loss patients, "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.  For example, a panniculectomy to eliminate a large hanging abdominal panniculus and its associated symptoms would be considered reconstructive.  In situations where a circumferential treatment approach is utilized to also treat the residual back and hip rolls or the ptotic buttock tissue, only the anterior portion of the procedures would be considered reconstructive, the remaining portion of the procedure would be considered cosmetic.  Only in rare circumstances will buttock, thigh or arm lifts be needed to treat functional abnormalities.  Typically these procedures are performed to improve appearance and are therefore cosmetic in nature." 1  

In this case, the patient had failed conservative treatment for her longstanding rashes including medical treatment by her primary care physician (PCP).  A panniculectomy will be sufficient to treat her rashes.  This procedure will eliminate the overhanging abdominal skin that predisposes the patient to recurrent skin infections.  Removal of redundant upper abdominal skin, diastasis repair and umbilical transposition are component parts of an abdominoplasty that are not necessary to treat the rashes.  According to the American Society of Plastic Surgeons (ASPS) guidelines, "Plication of the rectus abdominis muscle and/or translocation of umbilicus should be considered purely cosmetic and separately billed to the patient," an abdominoplasty is a cosmetic body contouring procedure that will not confer any additional functional benefit for this patient.  A panniculectomy with skin resection was sufficient to treat this patient's condition (i.e. infections).

The health plan acted reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the abdominoplasty (code 15847) for the diagnosis of redundant abdomen and atrophic disorder of the skin following beneficial weight loss should be upheld.  The medical necessity is not substantiated.