MEDICAL POLICY

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RATIONALE
REFERENCES
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APPENDIX
HISTORY

Panniculectomy and Excision of Redundant Skin

Number 7.01.523

Effective Date May 12, 2015

Revision Date(s) 05/12/15; 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

Panniculectomy may be considered medically necessary when the following criteria are met:

  • The panniculus hangs to or below the level of the pubis; AND
  • The panniculus causes chronic/persistent skin conditions that
  • Result in infection AND
  • Persists after 3-months of medical management (see Documentation required) AND
  • Causes a physical functional impairment that interferes with activities of daily living (ADLs) (See Policy Guidelines)

A panniculectomy performed at the time of an approved gastric restrictive surgery may be considered medically necessary when the criteria for medical necessity are met.

Panniculectomy surgery performed in the absence of a documented physical functional impairment and that does not meet the criteria for medical necessity is considered cosmetic.

An abdominoplasty, including a mini or modified abdominoplasty, is considered cosmetic as the procedure does not address any physical functional condition.

Procedures to remove redundant skin in the arms, buttocks, hips. legs, thighs, torso are considered cosmetic and include but are not limited to the following:

  • Belt Lipectomy
  • Circumferential Body Lift
  • Circumferential Lipectomy
  • Lipoabdominoplasty
  • Lower Body Lift
  • Suction Lipectomy
  • Torsoplasty

(See Related Policies for procedures not addressed in this policy)

Treatment of diastasis recti is considered cosmetic as the separation/laxity of the muscles of the abdominal wall is not considered a true hernia and the treatment does not address a physical functional condition. (See Definition of Terms)

Procedures are considered cosmetic when performed solely to improve physical appearance.

Related Policies

7.01.516

Bariatric Surgery

10.01.514

Cosmetic and Reconstructive Services

Policy Guidelines

Documentation Required

Panniculectomy Surgery

Written documentation in the medical record for panniculectomy surgery must include:

  • The specific physical functional impairment for the panniculectomy.
  • Front and lateral view photographs demonstrating redundant/excessive skin or the size of the panniculus
  • Clinical observations about the nature/extent of any chronic/persistent skin conditions present such as skin irritation or infection resulting in pain, ulceration, super pubic intertrigo, monilial infestation, or panniculitis. What medical treatments were tried for at least a 3-month period. (Examples of agents that may be used for conservative medical management are antifungal, antibacterial or moisture-absorbing agents, topically applied skin barriers, and supportive garments.)

Definition of Terms

(Terms taken in part from the American Society of Plastic Surgeons 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 diastasis and a neoumbilicoplasty.
  • 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 (monsplasty).
  • Circumferential Lipectomy combines an abdominoplasty or panniculectomy with flank and back lifts, both procedures being performed together sequentially and including suction assisted lipectomy, where necessary.
  • Cosmetic in this policy, cosmetic procedures/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.
  • Diastasis recti is a separation between the right and left side of the rectus abdominus muscles that cover the front of the abdomen. The separation appears as a ridge down the middle of the abdomen that does not lead to complications that need intervention. This condition does represent a true hernia.
  • Hernia Repairs 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. A true hernia repair should not be confused with diastasis recti repair that is part of a standard abdominoplasty.
  • 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.
  • 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.
  • 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.
  • 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.

Description

Excessive skin in the abdomen can be a result of the physical changes that occur with extreme weight loss following gastric restrictive surgery for obesity. Skin redundancy may be an end result of pregnancy or excessive weight gain. In a severely obese patient, excess adipose tissue and skin hanging downward from the umbilicus past the pelvis is referred to as a panniculus or pannus.

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 that may result in infections of the skin (fungal dermatitis, folliculitis, subcutaneous abscesses, ulcerations) or panniculitis. A panniculus complicates the surgery of a morbidly obese patient.

Panniculectomy surgery may be indicated to reduce the panniculus. The surgery is done solely to remove the excess skin that hangs over the abdominal area that interferes with a person’s ADLs and/or results in severe skin conditions. A panniculectomy does not tighten the abdominal muscles. Obese patients with a very large pannus or who have a massive weight loss that requires retraction of excessive skin may require more time consuming and involved procedures due to the severity of the defect.

A true ventral hernia that is large, symptomatic and not manually reducible may require surgery at the same time that a medically necessary panniculectomy is performed.

Surgery to reduce the amount of excess abdominal skin is often done solely for improving appearance without any evidence of physical functional/ADL impairment. An abdominoplasty, sometimes referred to as a “tummy tuck” is the most common cosmetic surgery performed to remove abdominal skin, fat and tighten flaccid muscles of 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.

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

A Benefit Advisory is recommended.

Rationale

This policy was created in 2005 and updated annually with a MEDLINE literature review. The most recent literature review was through March, 2015.

Shermak believed that patients who sustain massive weight loss after open gastric bypass are prone to incisional hernias. (1) 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. (2, 3) 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.

Practice Guidelines and Position Statements

American Society of Plastic Surgeons (ASPS)

According to the ASPS (2) Surgical treatment of skin redundancy for obese and massive weight loss patients (1) recommended insurance coverage criteria for third-party payers includes:

  • 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 and not a compensable procedure.
  • A panniculectomy to eliminate a large hanging abdominal panniculus and its associated symptoms would be considered reconstructive
  • Where a circumferential treatment approach is utilized to also treat the residual back and hip rolls or the ptotic buttock tissue, only the anterior portion of the procedures would be considered reconstructive, the remaining portion of the procedure would be considered cosmetic
  • Only in very rare circumstances will buttock, thigh or arm lifts be needed to treat functional abnormalities. Typically these procedures are performed to improve appearance and are therefore cosmetic in nature.

References

  1. Shermak MA. Hernia repair and abdominoplasty in gastric bypass patients. Plast Reconstr Surg 2006; 117(4):1145-50; discussion 1151-2. PMID 16582778
  2. 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. And http://www.plasticsurgery.org/Documents/medical-professionals/health-policy/evidence-practice/Surgical-Treatment-of-Skin-Redundancy-Following-Massive-Weight-Loss.pdf. Last accessed April, 2015.
  3. 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 April, 2015.
  4. Seung-Jun O, Thaller SR. Refinements in abdominoplasty. Clin Plast Surg 2002 Jan; 29(1):95-109, vi. PMID 11827371
  5. Trussler AP, Kurkjian TJ et al. Refinements in abdominoplasty: A critical outcomes analysis over a 20-year period. Plast Reconstr Surg. 2010 Sep;126(3):1063-74. PMID 20811239
  6. Heller JB, Teng E, Knoll BI, Persing J. Outcome analysis of combined lipoabdominoplasty versus conventional abdominoplasty. Plast Reconstr Surg. 2008;121(5):1821-1829. PMID 18454008
  7. Robertson JD, de la Torre JI, Gardner PM et al. Abdominoplasty repair for abdominal wall hernias. Ann Plast Surg 2003; 51(1):10-16. PMID 12838119
  8. Bonatti H, Hoeller E, Kirchmayr W et al. Ventral hernia repair in bariatric surgery. Obes Surg 2004 May; 14(5):655-658. PMID 15186634
  9. Matarasso A. The male abdominoplasty. Clin Plast Surg 2004; 31(4):555-569, v-vi. PMID 15363909
  10. Mast BA. Safety and efficacy of outpatient full abdominoplasty. Ann Plast Surg 2005; 54(3):256-259. PMID 15725826
  11. Spector JA, Levine SM, Karp NS. Surgical solutions to the problem of massive weight loss. World J Gastroenterol 2006; 12(41): 6602-6607.PMID 17075971
  12. Gusenoff JA, Rubin JP. Plastic surgery after weight loss: current concepts in massive weight loss surgery. Aesthet Surg J. 2008;28(4):452-455. PMID 19083561

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

     
     
     
     
     
     

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 relate to adjudication of the policy.

05/12/15

Annual Review. Abdominoplasty removed from title. Title changed to Panniculectomy and excision of redundant skin. Procedures considered as cosmetic to excise redundant skin in other body areas listed in the Policy section. Statements added that abdominoplasty & diastasis recti surgery is considered cosmetic. Policy updated with literature search through March 2015. Definition of Terms consolidated into the Policy Guidelines Section. Documentation requirements reformatted as bullet points. ASPS’ recommended coverage criteria added to Practice Guidelines section. CPT codes related to covered ventral hernia repair were removed 49560, 49561, 49565, 49566, 49568, and 49656. Policy statements changed as noted.


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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