Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for panniculectomy.Findings:  The physician reviewer found that records support that this patient has a pannus as charted by one provider in her operative notes, by a second provider in visit notes, and in the photographs. However, there is a lack of documentation that the patients pannus is causing significant functional problems or systemic illness to support an indication for panniculectomy to support the medical necessity of the requested panniculectomy. The patient is able to work, perform activities of daily living, and wear clothing. Womens pants  and skirts typically fit at mid-waist. The pictures provided suggest that the patient should be able to wear pants and skirts. According to Ali and colleagues, a patients pannus is excess skin and soft tissue that hangs below the umbilicus. The authors noted that a pannus may develop into a pathologic entity in obese patients causing infections skin ulcerations as well as difficulty with hygiene. Janis and colleagues commented that when a patients pannus leads to significant functional problems, rashes, or systemic illness, then resection of the pannus can be addressed with an abdominal contouring procedure. The two most common abdominal contouring procedures are panniculectomy and abdominoplasty. Both panniculectomy and abdominoplasty involve removing the excess skin and soft tissue of the lower abdomen, while abdominoplasty also includes a fascial plication of the abdominal wall. The authors noted that a panniculectomy is performed to relieve functional symptoms from excess abdominal skin and subcutaneous tissue, while abdominoplasty is performed for cosmetic reasons. Similarly, Janis and colleagues concluded that the goal of panniculectomy is to relieve the symptoms caused by excess skin. Accordingly, the requested panniculectomy is not medically necessary for 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. Applying this statute, the requested panniculectomy is reconstructive in nature for treatment of this patient. The patient is obese and has a pannus, but this is not considered an abnormal structure of the body caused by congenital defect, developmental abnormality, infection, tumor, or disease. On review of this patients records, the patients pannus is an abnormality that occurred after surgery, which is due to trauma. The provider did not chart the presence of a pannus in the patients history and physical, but the provider reported that the patient had a pannus in the operative note. The photographs show the patient wearing sweatpants that fit properly with some evidence of a slightly larger pannus on the left side than on the right. On review of the available documentation and photographs, the requested panniculectomy will improve the appearance of the patients defect that was created by surgery. The panniculectomy will require removal of more tissue on the left side than on the right side to create a more normal appearance. Based on the medical information received, the requested panniculectomy is likely to provide more than a minimal improvement in the patients appearance. Therefore, the requested panniculectomy is reconstructive in nature for treatment of this patient. Given these findings, the requested panniculectomy is medically necessary and reconstructive in nature for treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary and reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be 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.