Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Panniculitis

Treatment: 15830 (excision, excessive skin and subcutaneous tissue [includes lipectomy]; abdomen, infraumbilical panniculectomy, and 15847 (excision, excessive skin and subcutaneous tissue [includes lipectomy], abdomen [eg, abdominoplasty] [includes umbilical transposition and fascial plication]).  

The insurer denied coverage for 15830 (excision, excessive skin and subcutaneous tissue [includes lipectomy]; abdomen, infraumbilical panniculectomy, and 15847 (excision, excessive skin and subcutaneous tissue [includes lipectomy], abdomen [eg, abdominoplasty] [includes umbilical transposition and fascial plication]).  

The denial is upheld

The panniculectomy and abdominoplasty are not medically necessary.  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 impairment.  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.  

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 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 percent (%).  In addition, 41% had minor complications, such as seromas, hematomas, wound healing problems, and wound dehiscence.  

Therefore, conservative, non-operative treatment would be standard of care, such as improved hygiene, topical creams or powders, and watchful waiting.  Surgical lipectomy would 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 medical judgment in the best interest of the patient.

The insurer's denial of coverage for 15830 (excision, excessive skin and subcutaneous tissue [includes lipectomy]; abdomen, infraumbilical panniculectomy, and 15847 (excision, excessive skin and subcutaneous tissue [includes lipectomy], abdomen [e.g., abdominoplasty] [includes umbilical transposition and fascial plication]) is upheld.  Medical Necessity is not substantiated.