Intertrigo 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 for mastopexy (CPT 19371) and breast reduction (CPT 19318). Findings: The physician reviewer found that Cabral and colleagues state that, “Women with increased breast size experience symptoms such as pain in the neck, shoulders and lumbar spine, headache, intertrigo in the inframammary fold, difficulty in performing daily activities, paresthesia in the hands, difficulty in exercising, low self-esteem, and body dissatisfaction.” The American Society of Plastic Surgeons (ASPS) states that reduction mammaplasty authorization should be based on documentation of the severity of the symptoms of macromastia and impact on health-related quality of life with at least two of the following signs: (1) chronic breast pain due to weight of the breasts; (2) intertrigo unresponsive to medical management; (3)…

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for (1) surgery to remove excessive skin from bilateral arms and (2) surgery to remove excessive skin from bilateral thighs. Findings: The physician reviewer found that The submitted documentation supports the medical necessity of a portion of the requested services. 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.

Where the denial was upheld

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for panniculectomy. According to the American Society of Plastic Surgeons (ASPS), 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. One study stated 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. According to the American Society of Plastic Surgeons (ASPS), a panniculectomy involves the removal of hanging excess skin and fat in a transverse or vertical wedge but does not include muscle plication, neoumbilicoplasty, or flap elevation. 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.

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 intertrigo, then check the rights and deadlines that apply to your plan.