Excess Abdominal Skin denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for a panniculectomy for treatment of the enrollee’s excess skin in the abdominal area. Findings: The physician reviewer found that there is sufficient support in the documentation for the requested services in this clinical setting. The photographs show evidence of a significantly abnormal asymmetric lower abdominal pannus as well as significant protuberance on profile view. Additionally, there appears to be an irregular scar deformity of the lower abdomen, as well. The documentation shows a severely abnormal abdomen as the result of previous major intra-abdominal surgery. Common functional problems associated with an overhanging pannus or skin redundancy are disabling rashes, pain, physical limitation, and back strain.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for an abdominal panniculectomy. Findings: The submitted documentation supports the medical necessity of the requested services. The records document evidence of an overlapping, symptomatic lower abdominal pannus. She has well-documented functional impairment with chronic rashes, consistent with chronic fungal infections, as well as lower back pain. She has attempted conservative management with topical dermatologic treatment. The medical evidence supports the requested services in this clinical setting. Thus, the requested abdominal panniculectomy is medically necessary for the treatment of this patient.In this patient’s case, the lower overhanging abdominal pannus is considered an abnormal structure of the body.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for panniculectomy (removal of extra skin from the area of the stomach) (CPT 15830)(CPT 22999). Findings: The physician reviewer found that At issue is whether the requested panniculectomy (removal of extra skin from the area of the stomach) (CPT 15830)(CPT 22999) is medically necessary to treat the patient’s medical condition. Does the condition constitute an abnormal structure of the body? If so, is the abnormal structure of the body caused by any of the following: congenital effects, 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?

Nature of Statutory Criteria/Case Summary: The patient who was diagnosed with obesity. She underwent a sleeve gastrectomy and lost a significant amount of weight, resulting in loose and excess abdominal tissue. The patient reported frequent rashes and difficulty with hygiene due to the excess lower abdominal skin. The patient’s body mass index was 32.81. Her abdominal pannus was noted to cover the region of the mons pubis. No evidence was noted of a rash under the skin fold, and no active wounds or infections were present. Preoperative photographs demonstrate a large lower abdominal pannus that hangs below the pubis. There is also a smaller upper abdominal pannus overhanging the umbilical area. The patient has requested reimbursement for abdominoplasty with flank liposuction surgery that was provided.

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 excess abdominal skin, then check the rights and deadlines that apply to your plan.