Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for panniculectomy. According to the American Society of Plastic Surgeons (ASPS), when surgery to remove extensive skin redundancy and fat folds is performed solely to enhance a patients 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. Sachs and colleagues noted that in order for a panniculectomy to be considered medically necessary, the patient should have documentation of a pannus that hangs below the level of the pubis confirmed with photographs. The authors commented that, Patients must fail medical treatment of intertrigo for three months. Medical treatment includes good hygiene, topical antifungals, corticosteroids, and antibiotics. The authors concluded that, The role of panniculectomy is to restore normal function. Patients must maintain a stable weight for at least six months. After bariatric  surgery, patients must maintain a stable weight for at least 18 months, including the most recent six months. This patients records provide documentation of a panniculus that hangs well below the level of the pubis. The provider reports that the patient has a recurrent rash underneath the abdominal pannus, which has recurred despite adequate treatment with miconazole cream and Bactroban ointment in addition to over the counter remedies. The patient has a functional problem with a recurring rash that has been demonstrated to be resistant to appropriate medical treatment. Based on the current medical literature and ASPS recommendations, the requested panniculectomy is medically necessary for treatment of this patient. The California Reconstructive Surgery Statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function; (2) to create a normal appearance, to the extent possible. The records demonstrate that this patient has a large lower abdominal pannus as a result of massive weight loss. The patients large lower abdominal pannus is the cause of recurring intertrigo that has been unresponsive to appropriate medical management. The patients large abdominal pannus constitutes an abnormal structure of the body caused by a developmental abnormality. In addition, the purpose of the requested panniculectomy is to improve function. Given these findings, the requested panniculectomy is reconstructive in nature for treatment of this patient. All told, the requested panniculectomy is medically necessary and reconstructive in nature for this patient. Final Result: The reviewer determined that the requested services are medically necessary and reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.