Abdominoplasty denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for abdominoplasty; endoscopic brow lift (bilateral); lower lid blepharoplasty (bilateral); upper lid blepharoplasty (bilateral); rhytidectomy (forehead); rhytidectomy (glabellar frown lines); rhytidectomy (cheek, chin, neck); rhytidectomy (SMAS flap); neck lift (platysma flap, p-flap); excision, excessive skin and subcutaneous tissue (includes lipectomy); bilateral thighs; and rhinoplasty, complete (osteotomies, nasal tip, cartilage). The requested abdominoplasty, as well as the requested lipectomy and excess skin removal of the thighs, seem to be in line with prior approved body contouring and may be considered masculinizing in effect.

Findings: The physician reviewer found that An enrollee has requested authorization and coverage for panniculectomy (CPT code 15830) and abdominoplasty (CPT code 15847).At issue is whether the requested panniculectomy (CPT code 15830) and abdominoplasty (CPT code 15847) are 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? If so, does the surgery provide more than a minimal improvement in the appearance of the patient?In this case, the patient’s panniculus hangs below the level of the pubis.

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 abdominoplasty, panniculectomy, liposuction of the thighs, liposuction of the abdomen, lipectomy, and/or breast lift. As noted by expert studies in the field, abdominoplasty, panniculectomy, and abdominal lipectomy involve surgical removal of excessive fat and skin from the abdomen. Per the studies, when surgery is performed to alleviate such complicating factors as the inability to walk normally, chronic pain, ulceration created by the abdominal skin fold, or intertrigo dermatitis, and the symptoms have been present for at least three months and are refractory to usual standard medical therapy, such surgery may be considered reconstructive.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for surgical procedures. According to medical study guidelines, 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. Similarly, in the case of skin laxity requiring resection with a panniculectomy, the authors reported 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.

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