Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pannus with recurrent rashes
Treatment: Panniculectomy
The insurer denied the Panniculectomy.
The determination is overturned.

The patient lost weight following bariatric surgery. He complains of recurrent rashes in the folds under his pannus. He has treated the rashes with topical prescription medications and special washes. He has also used hydrocortisone, A&D ointment, and antifungal medications. Dermatology evaluated the patient and recommend pannus removal. Photos show a male with an abdominal pannus. A panniculectomy is planned and is under review for medical necessity.

A panniculectomy (15830) is medically necessary. According to the American Society of Plastic Surgeons (ASPS) Position Paper "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." The records indicate that the patient has failed conservative treatment for his longstanding rashes, including treatment by his primary care physician (PCP) and dermatologist. Photos show a male with a pannus that hangs to the pubis. A panniculectomy will eliminate his rashes and allow him to comfortably wear his police vest and holster at work. The patient's condition also meets the InterQual guidelines for a panniculectomy. According to the InterQual guidelines, panniculectomy is medically necessary if any one of the following guidelines are met:

1) Inability to maintain hygiene of the lower abdominal and genital area. 2) Non-healing ulceration under the pannus. 3) Chronic maceration of overhanging skin folds. 4) Recurrent skin infection under panniculus despite treatment for 12 weeks. 5) Severe lower back pain and other etiologies excluded.

The patient has chronic maceration, recurrent skin infections and an inability to maintain hygiene of the lower abdominal and genital areas. He has been treated for months with over the counter and prescription topical medications.
Finally, the patient's condition meets the Milliman Care Guidelines (MCG), 24th Edition for Panniculectomy. Per the guidelines:

Panniculectomy may be indicated when ALL of the following are present:
1) Patient has complications from panniculus (eg, chronic or recurrent intertrigo, other skin infection, ulceration, or skin irritation that has been persistent despite nonsurgical treatment). 2) Pannus interferes with activities of daily living. 3) Patient's weight has reached stable plateau, and 1 or more of the following: 4) Adherence to multidisciplinary nonsurgical program of weight maintenance. 5) One year or more has elapsed following bariatric surgery.
The patient has persistent rashes despite months of medical treatment including prescription topical medications. The records confirm problems with activities of daily living. Photos show a long pannus that interferes with ability to wear his police belt and vest. His weight is stable.
Based on the ASPS, MCG, and InterQual guidelines, a panniculectomy is medically necessary for this patient.