Appeal type: Medical Necessity
Decision: Overturned

Findings:  The physician reviewer found that An enrollee has requested authorization and coverage for panniculectomy (CPT code 15830) and abdominoplasty (CPT code 15847).At issue is whether the requested panniculectomy (CPT code 15830) and abdominoplasty (CPT code 15847) are 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?In this case, the patients panniculus hangs below the level of the pubis. The patient complains of a recurrent rash underneath their abdominal pannus. The rash has continued to recur despite medical treatment with antifungal powder. The patient has a functional problem with the rash that has been demonstrated to be resistant to appropriate medical treatment. Based on the current evidence-based literature, the requested panniculectomy (CPT code 15830) is medically necessary for treatment of the patients medical condition.According to the American Society of Plastic Surgeons, A cosmetic abdominoplasty is sometimes performed at the time of a functional panniculectomy or delayed pending completion of weight reduction. Abdominoplasty, typically performed for cosmetic purposes, involves the removal of excess skin and fat from the pubis to the umbilicus or above, and may include fascial plication of the rectus muscle diastasis and a neoumbilicoplasty. Abdominoplasty is typically performed for cosmetic purposes. In this case, the patient has a prominent abdomen with loose skin. There is no health issue or functional disability as a result of the patients condition. Therefore, the requested abdominoplasty (CPT code 15847) is not medically necessary for 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. A prominent abdomen is not an abnormal structure of the body. It is not a result of congenital defects, developmental abnormalities, trauma, infection, tumors, or disease. Additionally, no functional deficit is reported to be present. The appearance is normal and consistent with gain and loss of weight. Therefore, the requested abdominoplasty (CPT code 15847) is not reconstructive in nature. Final Result: The reviewer determined that some of the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially 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.