Panniculectomy denials in California external review

What the reviewers wrote

Where the denial was overturned

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for flap island pedicle breast reconstruction and abdominoplasty. Surgical breast procedure to utilize excess loose abdominal tissue (excision excessive skin and subcutaneous tissue, abdomen, infraumbilical panniculectomy) as a replacement for skin and volume loss of the left breast lower pole and formation of an island pedicle flap.

Findings: The physician reviewer found that the patient requested authorization and coverage for panniculectomy, abdominoplasty, mastopexy, and breast reduction and augmentation.A review of medical literature reveals that panniculectomy is crucial not only for improving physical appearance but also for addressing functional issues such as skin irritation and rashes caused by excess skin. This procedure addresses the excess skin and pannus causing skin irritation, rashes, and functional issues such as difficulty with hygiene and the potential risk of infection. Removing the excess skin is beneficial for physical comfort and hygiene but also serves a reconstructive purpose by restoring a more functional and normal appearance to the abdominal area. However, abdominoplasty, which is the tightening of the abdominal muscles, is not medically appropriate as it is 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 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 Panniculectomy, then check the rights and deadlines that apply to your plan.