Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Excess Abdominal Skin

Treatment: Ambulatory Surgery (Outpatient Services [15830x1, 15836x1])

The insurer denied coverage for Ambulatory Surgery (Outpatient Services [15830x1, 15836x1].)

The denial is upheld. 

This is a patient who had gastric bypass performed over two years ago to help with the management of morbid obesity and chronic back and knee pain.  The patient has since experienced loose abdominal pannus, which has impacted the patient's self-esteem and activities of daily living (ADL).  The patient also reports multiple episodes of skin breakdown that are very painful.  The request is for a panniculectomy, which the insurer has denied as not medically necessary.

After review of the medical records provided, the panniculectomy is not considered medically necessary.  The patient does have documented issues with depression, anxiety, and self-esteem as a result of their loose abdominal pannus.  However, surgery to improve self-esteem is cosmetic.  With regard to the rashes, 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's. 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.
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 Ambulatory Surgery (Outpatient Services [15830x1, 15836x1]) is not substantiated.