MEDICAL POLICY

POLICY
RELATED POLICIES
POLICY GUIDELINES
DESCRIPTION
SCOPE
BENEFIT APPLICATION
RATIONALE
REFERENCES
CODING
APPENDIX
HISTORY

Abdominoplasty/Panniculectomy/Ventral Hernia Repair/Skin Redundancy

Number 7.01.523

Effective Date March 25, 2014

Revision Date(s) 03/10/14; 03/08/13; 03/13/12; 02/08/11; 01/12/10; 02/10/09; 04/08/08; 06/12/07; 05/09/06; 05/10/05

Replaces N/A

Policy

Abdominoplasty/panniculectomy/Belt Lipectomy/Torsoplasty/Circumferential/Lower body lift may be considered medically necessary when the following criteria are met:

  • The panniculus hangs to or below the level of the pubis; AND
  • The patient’s medical record documents that the panniculus causes a physical functional impairment such as skin irritation or infection resulting in pain, ulceration, super pubic intertrigo, monilial infestation, or panniculitis that is chronic, persistent and refractory to medical treatment for at least a 3-month period. (Examples of agents that may be used for conservative treatment are antifungal, antibacterial or moisture-absorbing agents, topically applied skin barriers, and supportive garments.)

The repair of a true incisional or ventral hernia may be considered medically necessary.

Abdominoplasty/panniculectomy performed in the absence of documented physical functional impairment is considered cosmetic.

Related Policies

7.01.516

Bariatric Surgery

10.01.514

Cosmetic and Reconstructive Services

Policy Guidelines

Written documentation from the medical record specifying the physical functional impairment for the abdominoplasty/panniculectomy, according to the above criteria, is required.

Front and lateral view photographs demonstrating redundant or excessive skin or the size of the panniculus and the nature and extent of skin irritation, cellulitis, ulceration, or skin necrosis are required.

Ventral hernia repairs require documentation of the size of the hernia, whether the ventral hernia is reducible, whether the hernia is accompanied by pain or other symptoms, whether there is a defect (as opposed to mere thinning) of the abdominal fascia, and office notes indicating the presence and size of the defect.

Description

The following definitions are derived from the American Society of Plastic Surgeons (ASPS) Position Papers.

Abdominoplasty 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 diatasis and a neoumbilicoplasty.

Mini or modified abdominoplasties are performed on patients with a minimal to moderate defect as well as mild to moderate skin laxity and muscle flaccidity and do not usually involve fascial plication above the umbilical level or neoumbilicoplasty.

Panniculectomy involves the removal of hanging excess skin/fat in a transverse or vertical wedge but does not include fascial plication, neoumbilicoplasty or flap elevation. A cosmetic abdominoplasty is sometimes performed at the time of a functional panniculectomy. Obese patients with a very large pannus or massive weight loss patients that require retraction of excessive skin may require more time consuming and involved procedures due to the severity of the defect. The panniculus can cause difficulty fitting into clothing, interference with personal hygiene, impaired ambulation and be associated with lower back pain or pain in the panniculus itself. The redundant skin folds are predisposed to areas of intertrigo, which can give rise to infections of the skin (fungal dermatitis, folliculitis, subcutaneous abscesses, ulcerations) or panniculitis.

Belt Lipectomy is a circumferential procedure which combines the elements of an abdominoplasty or panniculectomy with removal of excess skin/fat from the lateral thighs and buttock. The procedure involves removing a “belt” of tissue from around the circumference of the lower trunk which eliminates lower back rolls, and provides some elevation of the outer thighs, buttocks, and mons pubis. Similarly, a circumferential lipectomy describes an abdominoplasty or panniculectomy combined with flank and back lifts.

Torsoplasty is a series of operative procedures, usually done together to improve the contour of the torso, usually female (though not exclusively). This series would include abdominoplasty with liposuction of the hips/flanks and breast augmentation and/or breast lift/reduction. In men, this could include reduction of gynecomastia by suction assisted lipectomy/ultrasound assisted lipectomy or excision.

Circumferential lipectomy combines an abdominoplasty with a “back lift”, both procedures being performed together sequentially and including suction assisted lipectomy, where necessary.

Lower body lift is a procedure that treats the lower trunk and thighs as a unit by eliminating a circumferential wedge of tissue that is generally, but not always, more inferiorly positioned laterally and posteriorly than a belt lipectomy. The procedure lifts tissues all the way from knee level and reduces, but does not eliminate, the need for subsequent thigh lifts. A lower body lift tends to stress thigh lifting along with truncal improvement.

Hernia repairs. A true hernia repair involves opening fascia and/or dissection of a hernia sac with return of intraperitoneal contents back to the peritoneal cavity. A true hernia repair should not be confused with diastasis recti repair, which is part of a standard abdominoplasty. A ventral hernia may be embedded in a panniculus and a panniculectomy may be a necessary adjunct to the ventral hernia repair to reconstruct the abdominal wall.

Scope

Medical policies are systematically developed guidelines that serve as a resource for Company staff when determining coverage for specific medical procedures, drugs or devices. Coverage for medical services is subject to the limits and conditions of the member benefit plan. Members and their providers should consult the member benefit booklet or contact a customer service representative to determine whether there are any benefit limitations applicable to this service or supply. This policy does not apply to Medicare Advantage.

Benefit Application

Some plan benefit descriptions specifically exclude services for or related to removal of excess skin following weight loss, regardless of physical functional impairment.

For the purposes of this policy, the following terms are defined below:

Cosmetic: In this policy, cosmetic services are those which are primarily intended to preserve or improve appearance. Cosmetic surgery is performed to reshape normal structures of the body in order to improve the patient’s appearance or self-esteem.

Physical Functional Impairment: In this policy, physical functional impairment means a limitation from normal (or baseline level) of physical functioning that may include, but is not limited to, problems with ambulation, mobilization, communication, respiration, eating, swallowing, vision, facial expression, skin integrity, distortion of nearby body parts or obstruction of an orifice. The physical functional impairment can be due to structure, congenital deformity, pain, or other causes. Physical functional impairment excludes social, emotional and psychological impairments or potential impairments.

Reconstructive Surgery: In this policy, reconstructive surgery refers to surgeries performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors or disease. It is generally performed to improve function.

Refer to member contract language for any direct and specific exclusions regarding the performed services.

A Benefit Advisory is recommended.

Rationale

This policy was originally created in 2005 and updated annually.

Shermak believed that patients who sustain massive weight loss after open gastric bypass are prone to incisional hernias. The author retrospectively studied this patient population at the Johns Hopkins Medical Institution. From February 2001 to December 2003, 40 patients had hernia repairs in combination with abdominoplasty. (Average age was 42 while the average weight loss was 152 pounds.) The average body mass index (BMI) at the time of plastic surgery was 35.6. Average abdominal skin resection was 9.9 pounds. Hernia recurred in one patient with a BMI of 41.3 after heavy lifting within 1 year of hernia repair surgery. Other complications included wound-healing problems (20%). Seroma (12.5%); bleeding requiring surgical take-back (2.5%); suture abscess requiring surgical removal of suture (7.5%); bleeding anastomotic ulcer requiring transfusion (2.5%); and fatal pulmonary embolus (2.5%). Of this group, 60% had uncomplicated healing. Shermak concluded that hernias are safely and preferentially repaired at the time of removal of redundant abdominal panniculus. Shermak believes these are acceptable results in this patient group.

Body contouring after bariatric surgery is currently the fastest growing field within plastic surgery. Although bariatric procedures may produce impressive weight loss, people who achieve massive weight loss are often unhappy with the hanging folds of skin and subcutaneous tissue that remain. After massive weight loss, patients are left “deflated”. Patients go to plastic surgeons to address the deformities resulting from the massive weight loss.

References

  1. American Society of Plastic Surgeons (ASPS); Position Paper: Surgical Treatment of Skin Redundancy for Obese and Massive Weight Loss Patients. 2007. Arlington Heights IL. Available at: http://www.plasticsurgery.org/Documents/medical-professionals/health-policy/insurance/Surgical-Treatment-of-Skin-Redundancy-Following.pdf. Last accessed February 21, 2014.
  2. American Society of Plastic Surgeons (ASPS); Position Paper: Abdominoplasty and Panniculectomy Unrelated to Obesity or Massive Weight Loss. 2007. Arlington Heights IL. Available at: http://www.plasticsurgery.org/Documents/medical-professionals/health-policy/evidence-practice/AbdominoplastyAndPanniculectomy.pdf. Last accessed January 21, 2014.
  3. Seung-Jun O, Thaller SR. Refinements in abdominoplasty. Clin Plast Surg 2002 Jan; 29(1):95-109, vi.
  4. Robertson JD, de la Torre JI, Gardner PM et al. Abdominoplasty repair for abdominal wall hernias. Ann Plast Surg 2003; 51(1):10-6.
  5. Bonatti H, Hoeller E, Kirchmayr W et al. Ventral hernia repair in bariatric surgery. Obes Surg 2004 May; 14(5):655-8.
  6. Matarasso A. The male abdominoplasty. Clin Plast Surg 2004; 31(4):555-69, v-vi.
  7. Mast BA. Safety and efficacy of outpatient full abdominoplasty. Ann Plast Surg 2005; 54(3):256-9.
  8. Shermak MA. Hernia repair and abdominoplasty in gastric bypass patients. Plast Reconstr Surg 2006; 117(4):1145-50; discussion 1151-2.
  9. Spector JA, Levine SM, Karp NS. Surgical solutions to the problem of massive weight loss. World J Gastroenterol 2006; 12(41): 6602-6607.
  10. Gusenoff JA, Rubin JP. Plastic surgery after weight loss: current concepts in massive weight loss surgery. Aesthet Surg J. 2008;28(4):452-5.

Coding

Codes

Number

Description

CPT

15830

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

 

15832

Thigh

 

15833

Leg

 

15834

Hip

 

15835

Buttock

 

15836

Arm

 

15837

Forearm or hand

 

15838

Submental fat pad

 

15839

Other area

 

15847

Excision, excessive skin and subcutaneous tissue (includes lipectomy) abdomen (e.g., abdominoplasty) (includes umbilical transposition and fascial plication) (List separately in addition to code for primary procedure) (Use 15847 in conjunction with 15830)

 

17999

Unlisted procedure, skin, mucous membrane and subcutaneous tissue

 

49560

Repair initial incisional or ventral hernia; reducible

 

49561

Incarcerated or strangulated

 

49565

Repair recurrent incisional or ventral hernia; reducible

 

49566

Incarcerated or strangulated

 

49568

Implantable of mesh or other prosthesis for incisional or ventral hernia repair or mesh for closure of debridement for necrotizing soft tissue infection (List separately in addition to code for the incisional or ventral hernia repair)

 

49656

Laparoscopy, surgical, repair, recurrent incisional hernia (includes mesh insertion, when performed); reducible

ICD-9 Procedure

86.83

Size reduction plastic operation

Type of Service

Surgery

 

Place of Service

Inpatient

 

Appendix

N/A

History

Date

Reason

05/10/05

Add to Surgery Section - New Policy

05/09/06

Replace Policy - Policy reviewed with literature search; no change to policy statement.

06/06/09

Disclaimer and Scope update - No other changes.

02/26/07

Codes Updated - No other changes.

06/12/07

Replace Policy - Policy statement added for abdominoplasty/panniculectomy performed in the absence of documented physical functional impairment as cosmetic; criteria of the presence of a documented physical functional impairment added to medically necessary policy statement. Definitions for cosmetic, physical functional impairment and reconstructive surgery added to Policy Guidelines. References added.

04/08/08

Replace Policy - Policy updated with literature search. Policy statement to include “Belt Lipectomy/Torosoplasty/Circumferential/Lower body lift” as a medically necessary indication when criteria are met. Title expanded to add “skin redundancy”. Policy updated with definitions from the American Society of Plastic Surgeons. Code added.

01/13/09

Code Updates - Code 49656 added effective 1/1/09.

02/10/09

Replace Policy - Policy reviewed with literature search; no change to policy statement.

10/13/09

Cross Reference Update - No other changes.

01/12/10

Replace Policy - Policy updated with literature search; no change to the policy statement. Benefit Application clarified but intent is unchanged.

02/08/11

Replace Policy - Policy updated with literature search; no change to the policy statements.

09/23/11

Related Policies updated; 10.01.514 added.

03/23/12

Replace Policy – Policy updated with literature search; no change to the policy statements.

03/08/13

Replace policy. No change to the policy statements.

12/18/13

Update Related Policies. Edit title to 7.01.516.

03/10/14

Replace policy. No change to policy statements. ICD-9 diagnosis codes removed; they do not related to adjudication of the policy.


Disclaimer: This medical policy is a guide in evaluating the medical necessity of a particular service or treatment. The Company adopts policies after careful review of published peer-reviewed scientific literature, national guidelines and local standards of practice. Since medical technology is constantly changing, the Company reserves the right to review and update policies as appropriate. Member contracts differ in their benefits. Always consult the member benefit booklet or contact a member service representative to determine coverage for a specific medical service or supply. CPT codes, descriptions and materials are copyrighted by the American Medical Association (AMA).
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