Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Excess abdominal skin
Treatment: Excision of excessive skin and subcutaneous tissue (includes lipectomy; hip and excision of excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy.
The insurer denied the surgical procedure.
The health plan's determination is upheld.

The patient is a female who has lost over 150 pounds following bariatric surgery. She reports an inability to attend to daily activities and she has difficulty with clothing because of her circumferential excess abdominal skin. She notes poor posture and balance secondary to her abdominal deformity. She notes increasing lumbar pain secondary to the weight of her pannus. 
During the summer, she has an increased incidence of skin crease dermatitis that is treated with a topical ointment. Despite diet and exercise, she is unable to reduce the size of the pannus or alleviate any symptoms. The patient states alternative treatments such as an abdominal binder or girdle have not given her significant relief of her chronic symptoms. On examination, the patient is noted to have a very large overhanging abdominal pannus extending past the pubis; the lipodystrophy and skin ptosis extends circumferentially around the waistline. Her surgeon performed skin removal surgery. According to the patient's appeal letter, the patient had rashes that required treatment with anti-fungal creams and medicines.

The health plan, in its determination of medical necessity, acted reasonably, with sound medical judgment and in the best interest of the patient. The surgical procedures were not medically necessary.

Medical necessity for the surgical procedure of the panniculectomy and lipectomy is not established, and the patient's health plan does not allow for coverage for cosmetic or nonfunctional surgery. The panniculectomy and abdominoplasty are said to have been necessary to treat recurrent infections, but the records do not include objective evidence to verify the accuracy of the patient's history. The patient does not have medical record documentation over time (e.g., series of office notes, dermatology consultations, pharmacy prescription records) of skin infections in the abdominal fold, and photographs documenting cellulitis, ulcerations or rashes were not submitted.

The patient's appeal letter indicates that the patient had failed conservative treatment, but the primary care physician's (PCP) office notes confirming the failure of medical management are not provided. The medical records do not provide any documentation in the form of PCP or dermatology progress notes that describe ongoing clinically significant dermatologic problems that have either 1) never responded to topical therapy given or 2) despite initial response, have recurred and caused significant functional impairment.

The patient's condition does not meet the American Society of Plastic Surgeons (ASPS) criteria for third party coverage of skin resection following massive weight loss. According to the ASPS Position Paper "Treatment of Skin Redundancy Following Massive Weight Loss"(1), skin resection is medically necessary if "panniculitis or uncontrollable intertrigo is present." The records do not document panniculitis or the failure of medically supervised conservative therapy to control the patient's intertrigo.
The most appropriate treatment for this patient would have been an evaluation by a dermatologist or internist with appropriate, physician directed skin care. 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 and patient appeal letters without specific dates of treatments or medications prescribed do not provide sufficient documentation to confirm the failure of medically supervised care.

The health plan's determination of medical necessity is upheld in full.