Prior Authorization Request (Panniculectomy)

Date: [Submission date]

Patient Name: [Patient full name]

Date of Birth: [DOB]

Member ID: [Insurance member ID]

Requesting Physician: [Physician name, credentials, NPI]

Practice/Facility: [Practice or facility name]

Contact: [Phone] | [Fax]

Procedure Requested: Panniculectomy (CPT 15830)

Proposed Date: [Proposed surgery date if known]

Relevant Diagnoses: [ICD-10 codes with descriptions] (List codes relevant to pannus-related complications and comorbidities, e.g., L30.4 intertrigo, L02.211 cutaneous abscess, E66.01 obesity post-bariatric surgery.)

Medical Necessity Summary

[Summary paragraph] (3–5 sentences stating: chief problem of symptomatic abdominal pannus; anatomic severity relative to pubic symphysis; chronicity of skin complications and/or functional impairment; duration and failure of conservative management; photo documentation status.)

• Pannus extent: [At pubic symphysis / Below pubic symphysis / Covers genital crease or upper thighs]; [Pannus grade if applicable]; [Overhang measurement in cm if available]
• Skin complications: [Intertrigo / Dermatitis / Ulceration / Cellulitis / Candidiasis] with [frequency], [typical duration], [treatment requirements], [dates of recent episodes]
• Conservative treatment trial: [Specific interventions] for [duration in weeks/months] with [inadequate response / recurrence despite treatment]
• Functional impairment: [Ambulation limitation / Hygiene difficulty / Bathing/dressing/toileting interference / Work limitations / Assistive device interference] with [concrete examples]
• Weight stability: [Stable weight for specified months]; [Post-bariatric interval if applicable] (Include only if relevant to payer criteria.)
• Nicotine/smoking status: [Abstinent since date / Currently uses type and quantity / Never smoker] (Include cotinine testing status if required by payer.)
• Photo documentation: [Attached / Available upon request / Not obtained with reason]; Views: [Frontal standing / Lateral standing / Pannus-lift]

(Include only criteria supported by documentation. If required information is unknown, note as pending rather than inferring compliance.)

Clinical History

Symptom Onset and Course: [Onset timing], [progression], [frequency and duration of skin breakdown episodes], [known triggers].

Skin Complications: [Locations: infraumbilical fold / suprapubic / groin extension]; [Character: erythema / maceration / fissuring / ulceration / odor]; [Complications requiring escalation: ED visits / systemic antibiotics / wound care]; [Prior documented diagnoses].

Functional Impact: [Specific limitations: ambulation distance, gait disturbance, need to manually support pannus, inability to perform hygiene beneath fold, interference with bathing/dressing/toileting, work limitations, difficulty using assistive devices]. (Use concrete examples rather than general quality-of-life statements.)

[Patient-reported symptoms without current exam corroboration] (Include only if applicable; clearly label as patient-reported and note supporting documentation such as prior notes, photos, or prescriptions.)

Conservative Management History

(Time-anchor each entry with dates or duration. If dates are unknown, note that records are being obtained.)

Hygiene and Supportive Measures:

• [Intervention: cleansing routine / drying method / barrier protectants / moisture-wicking garments / supportive devices] — [Duration or dates]; [Adherence and limitations]; [Response]

Pharmacologic Treatments:

• [Agent name and strength], [frequency], [duration], [prescriber], [response] (List each medication tried: topical antifungals, topical corticosteroids, topical or oral antibiotics, oral antifungals, wound care products.)

Summary of Conservative Care Adequacy: [Statement of what was tried, total duration, and why insufficient: persistent symptoms / recurrent infections / non-healing ulcer / ongoing functional impairment]. (If documentation is incomplete, specify which records are being obtained.)

Weight History

(Include only when weight stability is relevant to payer criteria; otherwise omit this section entirely.)

Current: Height [value], Weight [value], BMI [value]

Peak Weight: [Highest known weight] around [approximate date]

Weight Loss: [Amount lost], [Method: bariatric surgery type and date / non-surgical], [Stability interval in months]

Post-Bariatric Timing: [Months since surgery]; [Duration of stable weight] (Include only for post-bariatric patients.)

Objective Findings

• Pannus Description: [Extent: at / below pubic symphysis / covering genitals or thigh crease]; [Overhang measurement in cm]; [Pannus grade if using standardized scale]
• Skin Examination: [Erythema / maceration / fissures / satellite lesions / ulcers with number, size, location, drainage / odor / signs of infection including warmth, tenderness, spreading erythema]
• Functional Observation: [Observed gait limitation / need to manually lift pannus / use of assistive devices and interference]
• Photographs: [Attached / Available upon request / Not obtained with reason]; Views: [Frontal standing / Lateral standing / Pannus-lift]; Date: [Photo date]

Medical Necessity Statement

[Medical necessity statement] (2–3 sentences explicitly requesting functional/reconstructive panniculectomy to treat chronic refractory skin disease and/or documented functional impairment. State that this is not a cosmetic contouring request. If concurrent procedures are planned, clarify that panniculectomy independently meets medical necessity criteria.)

Planned Procedure

• Operation: Panniculectomy
• Site of Service: [Outpatient surgery center / Hospital outpatient department / Inpatient]
• Expected Benefit: [Resolution of documented skin complications / Improvement in specified functional deficits]
• Perioperative Optimization: [Nicotine abstinence and testing status / Glycemic control / Other optimization steps] (Include only if relevant to payer requirements.)

Attachments

• Clinical photographs [attached / pending] — Date: [date]
• Office visit notes documenting severity and chronicity [attached / pending] — Dates: [dates]
• PCP, dermatology, or wound care notes [attached / pending] — Dates: [dates]
• Medication/pharmacy records [attached / pending]
• Weight documentation or bariatric surgery records [attached / pending / not applicable]
• Payer-specific prior authorization form [attached / not required]

Attestation

Attesting Physician: [Name, credentials]

Signature: [Signature]

Date/Time: [Date and time]

I attest that the information provided is accurate and complete to the best of my knowledge, based on direct examination of the patient and review of available medical records.