Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Rashes
Issue under review: Panniculectomy; Panniculectomy umbilical transfer

Determination:
The Panniculectomy is medically necessary. The Panniculectomy umbilical transfer is not medically necessary.

The patient is an adult female. She complains of rashes in the fold under her pannus. She has treated the rashes with Retin-A and Nystatin.  She has lost weight following bariatric surgery. Photos show a female with a pannus that does not hang to the pubis. Panniculectomy is planned.

According to the American Society of Plastic Surgeons Position Paper "Treatment of Skin Redundancy For Obese and Massive Weight Loss Patients,"(1) "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 with Nystatin and Retin A prescribed by her PCP. 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
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.

Finally, the patient's condition meets the Milliman Care Guidelines, 22nd Edition for panniculectomy. Per the guidelines:
Panniculectomy may be indicated when ALL of the following are present
Patient has complications from panniculus (eg, chronic or recurrent intertrigo, other skin infection, ulceration, or skin irritation that has been persistent despite nonsurgical treatment).
Pannus interferes with activities of daily living.
Patient's weight has reached stable plateau, and 1 or more of the following:
Adherence to multidisciplinary nonsurgical program of weight maintenance
One year or more has elapsed following bariatric surgery.

The patient has persistent rashes despite medical treatment. The records confirm problems with activities of daily living. Her weight is stable. 

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

A panniculectomy will be sufficient to treat the patient's rashes. This procedure will eliminate the overhanging abdominal skin that predisposes the patient to recurrent skin infections. Removal of redundant upper abdominal skin, diastasis repair and umbilical transposition are component parts of an abdominoplasty that are not necessary to treat the rashes. An abdominoplasty is a cosmetic body contouring procedure that will not confer any additional functional benefit for this patient. A panniculectomy with skin resection is sufficient to treat this patient's infections.