Ventral Hernia denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/ Case Summary: The enrollee is requesting authorization and coverage for a procedure to repair ventral hernia(s) and remove excessive and redundant skin and subcutaneous tissue of the abdomen and pannus. The enrollee has panniculitis. At an office visit, her general surgeon noted she had a ventral hernia and two umbilical hernias. The enrollee complained of excess skin that impeded her ability to undergo repair of her hernias. She also complained of a left groin bulge with associated pain. The enrollee previously weighed 445 pounds and now weighs 254 pounds. She has maintained this weight for the past three years with minor fluctuations. She was referred to a plastic surgeon, who noted the enrollee had a significant abdominal pannus, which may interfere with the hernia repairs due to the redundant skin and soft tissues.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for lipectomy/panniculectomy surgery after sleeve bariatric surgery performed to remove excess skin. Findings: The physician reviewer found that the requested lipectomy/panniculectomy surgery after sleeve bariatric surgery performed to remove excess skin is medically necessary for treatment of the patient’s medical condition. According to a study “The abdominal panniculus may cause disabling rashes, pain, physical limitation, back strain, and cosmetic deformity, and symptoms are more marked the heavier the panniculus.” In this case, the patient presents with evidence of a symptomatic abdominal pannus related to excess soft tissue from weight loss. Symptoms include sores, ulcers and rashes due to overlapping abdominal skin.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for panniculectomy. This patient presents with evidence of a relatively mild overlapping lower abdominal pannus in the setting of a ventral hernia. Based on the submitted documentation, there is insufficient medical documentation to support that the panniculectomy is required to address a functional deficit. From the American Society of Plastic Surgeons (ASPS) “a panniculectomy to eliminate a large hanging abdominal panniculus and its associated symptoms would be considered reconstructive.” Further, researchers noted that, “abdominal panniculus may cause disabling rashes, pain, physical limitation, back strain, and cosmetic deformity, and symptoms are more marked the heavier the panniculus. Panniculectomy can treat these symptoms”.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for hernia surgery. Findings: The physician reviewer found that Surgical repair of the ventral hernia is not recommended for this patient since the medical literature and guidelines have reported that hernia repair in patients with body mass index (BMI) greater than 35 kg/m2 is associated with high degree of recurrence, need for additional surgery, and increased morbidity. The available records document that this patient’s hernia is longstanding, contains only fat and is large in size. The provider’s description of the patient’s hernia suggest that it poses less risk of likely obstruction or incarceration, particularly since it is documented to be filled with fat. The patient has a BMI that is greater than 35 kg/m2, which places her at high risk of failure of ventral hernia repair.

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