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Private Property of Blue Cross and Blue Shield of Florida.
This medical policy (medical coverage guideline) is Copyright 2014, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2014 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

02-12000-16

Original Effective Date: 07/01/13

Reviewed: 06/27/13

Revised: 00/00/00

Subject: Panniculectomy and Abdominoplasty

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
Other References Updates      

DESCRIPTION:

Panniculectomy is the surgical removal of hanging excess skin/fat (panniculus, pannus, apron) from the abdomen via a transverse or vertical wedge, but does not include muscle plication, neoumbilicoplasty, or flap elevation. The excess abdominal skin and fat may hang down over the genital area and thighs, and rarely to the knees. The excess abdominal skin and fat may be accompanied by laxity of the anterior abdominal wall. According to the American Society of Plastic Surgeons (ASPS), the severity of abdominal deformities is graded as follows:

Grade 1: Panniculus covers hairline and mons pubis but not the genitals

Grade 2: Panniculus covers genitals and upper thigh crease

Grade 3: Panniculus covers upper thigh

Grade 4: Panniculus covers mid-thigh

Grade 5: Panniculus covers knees and below

Abdominoplasty, also referred to as a “tummy tuck,” is an excisional surgical procedure, which involves removal of excess abdominal skin (apron) and fat from the pubis to the umbilical or above, and may include fascial plication of the rectus muscle diastasis and a neoumbilicoplasty. This reshaping and contouring of the abdominal wall area is often performed solely to improve the appearance of a protuberant abdomen by creating a flatter, firmer abdomen. (American Society of Plastic Surgeons (ASPS), 2007)

There are similarities between an abdominoplasty and a panniculectomy procedure as both procedures remove varying amounts of abdominal wall skin and fat. According to the ASPS Practice Parameter for Abdominoplasty and Panniculectomy (2007), the procedures are most commonly performed for cosmetic indications. However, there are reconstructive indications such as abdominal wall defects, irregularities or pain caused by previous pelvic or lower abdominal surgery, umbilical hernias, intertriginous skin conditions and scarring. The ASPS recommended coverage criteria state that an abdominoplasty or panniculectomy should be considered a reconstructive procedure when performed to correct or relieve structural defects of the abdominal wall. When an abdominoplasty or panniculectomy is performed solely to enhance a patient's appearance in the absence of signs or symptoms of functional abnormalities, the procedure should be considered cosmetic.

The ASPS Practice Parameter for Surgical Treatment of Skin Redundancy Following Massive Weight Loss (2007) states that "body contouring surgery is ideally performed after the patient maintains a stable weight for two to six months. For post bariatric surgery patients, this often occurs 12-18 months after surgery or at the 25 kg/ mg2; to 30 kg/ mg2; weight range.”

Abdominal Surgeries and Gynecologic Surgeries

Abdominal surgeries (e.g., hernia repair, bariatric, exploratory laparotomy, caesarean section) and gynecologic surgeries (e.g., hysterectomy, pelvic surgical procedures) may be performed in conjunction with an abdominoplasty or panniculectomy. It has been proposed that performing abdominoplasty or panniculectomy in the obese patient at the time of abdominal and gynecologic surgeries may improve operative exposure, promote postoperative wound healing and minimize postoperative wound complications (e.g., dehiscence, necrosis, infection). There is insufficient evidence to support performance of abdominoplasty and panniculectomy at the time of abdominal and gynecologic surgeries.

Diastasis Recti

Diastasis recti (also known as abdominal separation) is a separation between the left and right side of the rectus abdominis muscle (covers the front surface of the abdominal area). Diastasis recti appear as a ridge running down the midline of the abdomen from the bottom of the breastbone to the navel. Diastasis recti are a common and normal condition in newborns. In pregnant women, increased tension on the abdominal wall may lead to diastais recti. Diastasis recti usually heal on its own, surgery may be needed if a hernia develops. According to the ASPS, “a true hernia repair involves opening fascia and/or dissection of a hernia sac with return of intraperitoneal contents back to the peritoneal cavity.”

POSITION STATEMENT:

NOTE: Coverage for panniculectomy and abdominoplasty is subject to the member’s benefit terms, limitations and maximums. Some plans may exclude coverage for panniculectomy and abdominoplasty as the member may not have a benefit for weight loss surgery or a complication of a non-covered service. If a pannus (panniculus) results from a contract excluded procedure such as bariatric surgery, the panniculectomy and abdominoplasty will also be considered an excluded procedure.

Refer to specific contract language regarding panniculectomy and abdominoplasty surgery.

Medical records, including photography and/or operative reports may be required to be submitted to the health plan for review.

Panniculectomy

Panniculectomy meets the definition of medical necessity when ALL of the following criteria are met:

Panniculus at grade 2 or above, using the following scale (medical records, including photography and/or operative reports may be required to be submitted to the health plan for review):

Grade 1: Panniculus covers hairline and mons pubis but not the genitals

Grade 2: Panniculus covers genitals and upper thigh crease

Grade 3: Panniculus covers upper thigh

Grade 4: Panniculus covers mid-thigh

Grade 5: Panniculus covers knees and below

AND

One of the following:

• Clinical documentation of recurrent chronic and persistent skin condition under panniculus (e.g., intertriginous dermatitis, panniculitis, cellulitis, non-healing skin ulceration, tissue necrosis, recurrent/persistent skin infection) unresponsive to 3 months of medical therapy (failed both oral and topical medications); OR

• Chronic maceration of overhanging skin folds that is refractory to medical therapy; OR

• There is a functional impairment, such as documented difficulty with ambulation due to the abdominal pannus.

AND

When ALL of the following criteria are met:

• There is a functional deficit due to a severe physical deformity or disfigurement resulting from the pannus; AND

• The surgery is expected to restore or improve the functional deficit; AND

• The pannus is interfering with activities of daily living.

Abdominal/Gynecologic Surgery

Panniculectomy meets the definition of medical necessity when performed in conjunction with an abdominal and intra-abdominal gynecologic surgery when required to improve operative exposure in extremely rare circumstances (Medical records, including photography and/or operative reports may be required to be submitted to the health plan for review).

Panniculectomy is considered experimental or investigational for minimizing the risk of hernia formation or recurrence.

Significant Weight Loss/Bariatric Surgery

Panniculectomy performed following *significant weight loss meets the definition of medical necessity when ALL of the following criteria are met:

• Meets ALL of the criteria listed above under “Panniculectomy” heading; AND

• Symptoms (persistent skin condition under panniculus, chronic maceration of overhanging skin) or functional impairment persists despite *significant weight loss which has been stable for at least 3 months or documented attempts at weight loss (medically supervised diet or bariatric surgery) have been unsuccessful; AND

• If the member has had bariatric surgery, they are at least 18 months post-operative or has documented stable weight for at least 3 months.

Note: *Significant weight loss varies based on the member’s clinical circumstances and may be documented when the member:

Reaches a body mass index (BMI) less than or equal to 30 kg/m2; OR

Has documented at least a 100 pound weight loss; OR

Has achieved a weight loss which is 40% or greater of the excess body weight that was present prior to the member's weight loss or surgical intervention.

Cosmetic/Non-Covered

NOTE: Coverage for cosmetic surgery is subject to the member’s benefit terms, limitations and maximums. Refer to specific contract language regarding cosmetic surgery.

Panniculectomy performed for cosmetic purposes (e.g., to improve, change, or enhance appearance in the absence of signs or symptoms of functional abnormalities, improve self-esteem, psychological symptomatology, psychological complaints) is considered cosmetic and not covered.

Panniculectomy performed for the treatment of back or neck pain is non-covered.

Abdominoplasty

Abdominoplasty (including mini abdominoplasty or modified abdominoplasty) for all indications with or without repair of abdominal wall laxity or diastasis recti is considered cosmetic and non-covered.

BILLING/CODING INFORMATION:

Panniculectomy and Abdominoplasty

The following codes may be used to describe panniculectomy and abdominoplasty.

CPT Coding:

15830

Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy

15847

Excision, excessive skin and subcutaneous tissue (includes lipectomy), abdomen (e.g., abdominoplasty) (includes umbilical transposition and fascial placation) (list separately in addition to code for primary procedure)

Mini Abdominoplasty and Modified Abdominoplasty

There is no specific code that describes mini abdominoplasty and modified abdominoplasty. The following code may be used to describe mini abdominoplasty and modified abdominoplasty.

CPT Coding:

17999

Unlisted procedure, skin, mucus membrane and subcutaneous tissue

REIMBURSEMENT INFORMATION:

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage products:

No National Coverage Determination (NCD) and/or Local Coverage Determination (LCD) were found at the time of the guideline development.

DEFINITIONS:

Abdominoplasty (tummy tuck): typically performed for cosmetic purposes, involves the removal of excess skin and fat from the pubis to the umbilicus or above, and may include fascial plication of the rectus muscle diastasis and neoumbilicoplasty.

Diastasis Recti: a separation between the left and right side of the rectus abdominis muscle, which covers the front surface of the abdominal area.

Intertrigo: inflammation produced by chafing of adjacent areas of skin.

Panniculectomy (apronectomy): involves the removal of hanging excess skin/fat in a transverse or vertical wedge but does not include muscle plication, neoumbilicoplasty or flap elevation. A cosmetic abdominoplasty is sometimes performed at the time of a functional panniculectomy or delayed pending completion of weight reduction.

OTHER:

Other names used to report panniculectomy and abdominoplasty:

- Panniculectomy (Apronectomy)

- Abdominoplasty (Tummy tuck)

REFERENCES:

  1. American Society of Plastic Surgeons Practice Parameter for Abdominoplasty and Panniculectomy Unrelated to Obesity or Massive Weight Loss, 2007.
  2. American Society of Plastic Surgeons Practice Parameter for Surgical Treatment of Skin Redundancy for Obese and Massive Weight Loss Patients, 2007
  3. American Society of Plastic Surgeons Recommended Insurance Coverage Criteria for Abdominoplasty and Panniculectomy Unrelated to Obesity or Massive Weight Loss, 2007.
  4. American Society of Plastic Surgeons Recommended Insurance Coverage Criteria for Surgical Treatment for Skin Redundancy for Obese and Massive Weight Loss Patients, 2007.
  5. InterQual Procedures Adult Criteria Panniculectomy, Abdominal, 2012.
  6. National Institutes of Health Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults, 1998.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 06/27/13.

GUIDELINE UPDATE INFORMATION:

07/02/13

New Medical Coverage Guideline.

Private Property of Blue Cross and Blue Shield of Florida.
This medical policy (medical coverage guideline) is copyright 2013, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2013 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association.The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

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Date Printed: April 24, 2014: 02:06 PM