Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient is requesting a panniculectomy. Findings: The physician reviewer found that The patient is diagnosed with obesity and intertrigo. The patient underwent a sleeve gastrectomy with subsequent conversion to a Roux-en-Y gastric bypass later. Physical examination findings included a large infraumbilical pannus extending below the level of the pubis with chronic skin hyperpigmentation, striae, and scarring. The skin was noted to be dry and a rash was present. The patients provider noted her skin was dry with no rash or erythema. The patient reported the excess skin caused rashes, skin irritation, and problems with movement and exercise. At issue, in this case is whether a panniculectomy is medically necessary for treatment of the patients medical condition. In addition, does the patients condition constitute an abnormal structure of the body? If so, is the abnormal structure of the body caused by any of the following: congenital abnormalities; 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 medical literature, researchers state that the criteria for treatment by panniculectomy is that the panniculus hangs below the level of the pubis. This patients medical records document that the panniculus causes chronic intertrigo, which has recurred over three months while receiving appropriate medical therapy. The patients panniculus hangs below the level of the pubis, and she endorsed skin breakdowns, infections, and chronic rashes underneath her abdominal pannus. Skin hyperpigmentation is present; however, the records do not document that the patient has a functional problem with a rash that has been resistant to appropriate medical treatment. Therefore, a panniculectomy is not medically necessary for the patient. Excess skin caused by obesity does not constitute an abnormal structure of the body. This patients abdominal pannus is not the result of a congenital defect, a developmental abnormality, trauma, infection, or disease. The records and photographs demonstrate that the patients pannus is a normal structural change that is an accommodative response to gain or loss of body mass. The appearance of the patient is normal and consistent with the gain and loss of weight. Therefore, the requested panniculectomy is not reconstructive in nature.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition and are 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.