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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for panniculectomy (removal of extra skin from the area of the stomach) (CPT 15830)(CPT 22999). Findings:  The physician reviewer found that At issue is whether the requested panniculectomy (removal of extra skin from the area of the stomach) (CPT 15830)(CPT 22999) is medically necessary to treat the patients medical condition. Does the condition constitute an abnormal structure of the body? If so, is the abnormal structure of the body caused by any of the following: congenital effects, developmental abnormalities, trauma, infection, tumors, or disease? If so, is the requested surgery performed to do either of the following: improve function or create a normal appearance to the extent possible? If so, does the surgery provide more than a minimal improvement in the appearance of the patient?According to the American Society of Plastic Surgeons, a panniculectomy involves the removal of hanging excess skin/fat in a transverse or vertical wedge but does not include muscle plication, neoumbilicoplasty or flap elevation. Al-Hadithy states that the criteria for treatment by panniculectomy are that (1) there has been at least 25% weight loss either following surgery or a planned weight loss program where the BMI is 30 or less for 12 months, (2) panniculus hangs below the level of the pubis, and (3) the medical records document that the panniculus causes chronic intertrigo that consistently recurs over three months while receiving appropriate medical therapy or remains refractory to appropriate medical therapy over a period of three months. In this case, the patients panniculus hangs below the level of the pubis. The patient complained of itchiness under her abdominal pannus. The patient denied skin infection or breakdown in the fold. Additionally, there is no report of appropriate medical treatment of the itchiness or of failure of appropriate medical treatment of a rash. The patient does not have a functional problem underneath her panniculus that has been demonstrated to be resistant to appropriate medical treatment. Therefore, the requested panniculectomy is not medically necessary for the treatment of the patients medical condition.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 patients condition is an abnormal structure of the body as a result of massive weight loss after a medically necessary procedure. In this case, there are no symptoms reported other than an itchiness underneath the pannus, so there is no functional loss. Additionally, the appearance is within the wide range of normal and is consistent with weight gain and loss. Therefore, the requested panniculectomy is not reconstructive in nature. Final Result: The reviewer determined that the requested service is not medically necessary for treatment of the patients medical condition and is not reconstructive in nature. Therefore, the Health Plans denial should be upheld.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.