Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Excess skin
Treatment: Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen infraumbilical panniculectomy (Code 15830) and Excision, excessive skin and subcutaneous tissue (includes lipectomy); other area (Code 15839)
The insurer denied: Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen infraumbilical panniculectomy (Code 15830) and Excision, excessive skin and subcutaneous tissue (includes lipectomy); other area (Code 15839)
The denial is Partially Overturned.

The patient is an adult female. She is status post bariatric surgery (Roux-en-Y) October 2020. She has lost about 124 pounds thus far. She has significant loose skin that is affecting her self-esteem as well as causing fungal functions and bacterial infections. Has noted loose skin in her triceps, bilateral inner thighs and around lower abdomen. She has had to use Mupirocin and oral antibiotics due to folliculitis and abscesses from loose skin related to her obesity. The primary location of the skin issues is in groin folds and inner thighs. The operation plan is to perform panniculectomy and mons plasty to help alleviate this patient's symptomatic abdominal pannus and mons in hopes of minimizing her recurrent rashes and redundant tissue that is hanging below the pubic synthesis after her greater than 100-pound weight loss.

The requested Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen infraumbilical panniculectomy (Code 15830) and Excision, excessive skin and subcutaneous tissue (includes lipectomy); other area (Code 15839) is medically necessary, in part. 

Specifically, Code 15830 is medically necessary, while Code 15839 is not medically necessary, as it is cosmetic. A panniculectomy (15830) is medically necessary. According to the American Society of Plastic Surgeons 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 her longstanding rashes, including treatment by her PCP (primary care provider) with mupirocin and Keflex. A panniculectomy will eliminate her rashes.
Code 15839 is cosmetic. A mons plasty is not necessary to treat the patient's rashes and will primarily improve appearance. Mons plasty is cosmetic and not medically necessary.