Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Skin chaffing and burning.
Treatment:  Panniculectomy and total body lift.

The insurer denied the panniculectomy and total body lift.  The denial is overturned, in part.

The patient is a female.  She presented with a 95-pound weight loss following gastric bypass surgery.  The patient complains of (c/o) skin chaffing and burning of bilateral inframammary folds, suprapubic region, bilateral hip and gluteal folds.  Persistent rashes and difficulty finding pants that fit her are noted, as well as hanging skin and fat deposits on her legs, thighs, buttocks and abdomen.  The patient's weight has plateaued and is noted to be stable for three months.  The patient has used over the counter (OTC) medications for her skin rashes, as well as oral steroids.  The physician notes that her pannus hangs over her pubic hair.  The physician plans panniculectomy and total body lift.

A panniculectomy is medically necessary, but the other requested procedures are cosmetic and are, therefore, not medically necessary.

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 a dermatologist.  Photos show rashes under the pannus fold.  A panniculectomy will eliminate her rashes. 

The patient's condition also meets the InterQual guidelines for a panniculectomy.  According to the InterQual guidelines, panniculectomy is medically necessary if any one of the following guidelines are met:  1) Inability to maintain hygiene of the lower abdominal and genital area, 2) Non-healing ulceration under the pannus, 3)  Chronic maceration of overhanging skin folds, 4) Recurrent skin infection under panniculus despite treatment for 12 weeks, or 5) Severe lower back pain and other etiologies excluded.

The patient has chronic maceration, recurrent skin infections and an inability to maintain hygiene of the lower abdominal and genital areas.  She has been treated for months with over the counter and prescription topical medications. 

Finally, the patient's condition meets the Milliman Care Guidelines, 24th Edition for panniculectomy.  Per the guidelines:

Panniculectomy may be indicated when ALL of the following are present:  1) Patient has complications from panniculus (e.g., chronic or recurrent intertrigo, other skin infection, ulceration, or skin irritation that has been persistent despite nonsurgical treatment), 2) Pannus interferes with activities of daily living, and 3) Patient's weight has reached stable plateau, and one or more of the following:  a) Adherence to multidisciplinary nonsurgical program of weight maintenance, b) One year or more has elapsed following bariatric surgery.

The patient has persistent rashes despite medical treatment including prescription topical medications.  The records confirm problems with activities of daily living.  Exam shows a long pannus that interferes with ability to wear clothing and ambulate.  Her weight is stable. 

Based on the ASPS, MCG, and InterQual guidelines, a panniculectomy is medically necessary for this patient.

The other requested body contouring procedures are not medically necessary.  The patient has generalized skin laxity consistent with the history of massive weight loss.  Correction of skin laxity following massive weight loss is generally considered cosmetic in the absence of clear and compelling documentation of specific signs and symptoms that 1) are clearly related to the excess skin, 2) are health threatening or cause significant functional disability, and 3) have failed to improve despite reasonable attempts at conservative therapy.  A reasonable standard for evaluating the medical necessity of potentially cosmetic surgery is whether the submitted records include convincing and confirmatory evidence of a chronic functional problem that has failed reasonable attempts at conservative therapy.  These proposed procedures do not meet this standard.  Other than the rashes under her abdominal pannus, the patient does not have medical record documentation over time (e.g., series of office notes, dermatology consultations, pharmacy prescription records) of skin fold, and photographs documenting cellulitis, ulcerations or rashes are not submitted.  In addition, the medical records do not provide any documentation in the form of primary care provider (PCP) or dermatology progress notes that describe ongoing clinically significant dermatologic problems in areas other than the abdominal pannus that have either 1) never responded to topical therapy given or 2) despite initial response, have recurred and caused significant functional impairment.   

According to the ASPS Position Paper "Treatment of Skin Redundancy Following Massive Weight Loss" (1), skin resection is medically necessary if "panniculitis or uncontrollable intertrigo is present...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 do not document panniculitis or the failure of medically supervised conservative therapy for body areas other than the abdominal pannus.  The most appropriate treatment for a patient such as this is an evaluation by a dermatologist or internist with appropriate, physician directed skin care if the patient is having rashes in areas other than the abdominal pannus.  Surgical lipectomy should be reserved for patients that have failed optimal medical management for intertrigo, which is not documented to be the case for this patient.  Summary treatment letters and patient appeal testimonies in the absence of physician office note documentation of specific dates of treatments and medications prescribed do not provide sufficient documentation to confirm the failure of medically supervised care.

The health plan should cover the panniculectomy, as it is medically necessary.  The health plan acted reasonably in denying the other requested procedures.