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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for an abdominal fleur-de-lis panniculectomy. According to the American Society of Plastic Surgeons (ASPS), 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. 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 state, A panniculectomy must meet specific criteria to be medically necessary. The pannus must hang below the level of the pubis and be confirmed with photography. Patients must fail medical treatment of intertrigo for three months. Medical treatment includes good hygiene, topical antifungals, corticosteroids, and antibiotics. 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. In this case, the panniculus hangs below the level of the pubis. The patient reports occasional rashes underneath her abdominal pannus, but the submitted documentation did not include reports of appropriate medical treatment of the rash or of failure of appropriate medical treatment of the rash. A physical examination reported irritation along the inguinal crease without distinct rashes. Current medical literature does not support panniculectomy for relief of low back pain. In this clinical setting, an abdominal fleur-de-lis panniculectomy is not medically necessary for the 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; or (2) to create a normal appearance, to the extent possible. In this case, the patient has an abdominal pannus that extends below the level of the pubis. The patient does not have functional disability from a chronic intractable rash under the pannus. The appearance is normal and consistent with gain and loss of weight and does not constitute an abnormal structure of the body. Accordingly, the requested abdominal fleur-de-lis panniculectomy is not reconstructive in nature for treatment of this patient.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.