Abdominal Pannus denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage reduction mammoplasty and panniculectomy. This patient presents with evidence of significant symptomatic bilateral macromastia that has failed reasonable conservative management. She has evidence of chronic neck, back and shoulder pain, as well as shoulder grooving and breast pain, which limit her daily activity. She has also a history of chronic rashes underneath her breasts that has failed typical conservative management with antifungal medication and creams. The medical documentation, including review of the photographs, supports that her macromastia is likely contributing significantly to her functional complaint of pain and chronic rashes. Moreover, she has failed typical conservative management including weight loss and typical dermatologic treatment.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for panniculectomy or treatment of the enrollee’s large pannus. Findings: The physician reviewer found that The request for panniculectomy is medically necessary for treatment of the patient’s medical condition. The patient presents with a severely enlarged abdominal pannus and has been recommended for a panniculectomy as a combined procedure with TAH/BSO. The combined procedure allows for greater access to the pelvis and may help prevent lower incisional maceration. The combined procedure of panniculectomy with TAH/BSO is supported as beneficial in the medical literature. On morbidly obese patients, the pannus will remain an obstacle during gynecologic surgery, which requires additional instrumentation or personnel to help retract it, to obtain proper exposure.

Where the denial was upheld

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient requested authorization and coverage for a panniculectomy.According to the American Society of Plastic Surgeons, 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. A study states that “A panniculectomy must meet specific criteria to be medically necessary. The pannus must hang below the level of the pubis and be confirmed with photography. Patients must fail medical treatment of intertrigo for three months. Medical treatment includes good hygiene, topical antifungals, corticosteroids, and antibiotics. The role of panniculectomy is to restore normal function.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for panniculectomy. The American Society of Plastic Surgeons (ASPS) has indicated that the criteria for the treatment of panniculectomy include documentation that the panniculus hangs below the level of the pubis and that the panniculus causes chronic intertrigo that consistently recurs over three months despite appropriate medical therapy. The photographs provided for review demonstrate that this patient’s panniculus hangs well below the level of the pubis. There are sores both in front of the abdominal pannus and underneath the abdominal pannus. Although there is mention of use of Nystatin, the records do not document the presence of chronic intertrigo that consistently recurs over three months despite appropriate medical therapy.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving abdominal pannus, then check the rights and deadlines that apply to your plan.