This policy addresses the surgical procedures panniculectomy and abdominoplasty and when they are considered medically necessary, not medically necessary and cosmetic.

Medically Necessary:

Panniculectomy is considered medically necessary for the individual who meets the following criteria:

1. The panniculus hangs below the level of the pubis (which is documented in photographs); AND
2. The individual has had significant weight loss of 100 pounds or more, as well as the following:
   • the individual has maintained a stable weight for at least six months AND
   • if the individual has had bariatric surgery, he/she is at least 18 months post operative; AND
3. One of the following:
   • there are recurrent or chronic rashes, infections, cellulitis, or non-healing ulcers, that do not respond to conventional treatment for a period of 3 months; information must be documented in office visit records; OR
   • there is difficulty with ambulation and interference with the activities of daily living; information must be documented in office visit records.

Panniculectomy is considered medically necessary as an adjunct to a medically necessary surgery when needed for exposure in extraordinary circumstances.

Not Medically Necessary:

Panniculectomy is considered not medically necessary when the criteria above are not met.

Panniculectomy is considered not medically necessary as an adjunct to other medically necessary procedures, including, but not limited to, hysterectomy, and/or incisional or ventral hernia repair unless the criteria above are met.

Panniculectomy or abdominoplasty, with or without diastasis recti repair, for the treatment of back pain is considered not medically necessary. 

Cosmetic:

Liposuction is considered cosmetic for all indications.

Abdominoplasty when done to remove excess skin or fat with or without tightening of the underlying muscles is considered cosmetic.

Repair of diastasis recti is considered cosmetic for all indications.

The current medical evidence addressing the efficacy of panniculectomy consists mostly of individual case reports and review articles. There have been only a very limited number of small-scale controlled trials on the subject. However, there is adequate clinical opinion to support the use of this procedure in limited circumstances where a patient’s health is jeopardized. The 1996 position paper from the American Society of Plastic and Reconstructive Surgeons on the treatment of skin redundancy following massive weight loss states resection of redundant skin and fat folds is medically indicated if panniculitis or uncontrollable intertrigo is present.

Our policy position for panniculectomy requires the loss of greater than or equal to 100 pounds, weight stability for 6 months and a waiting period of 18 months following bariatric surgery (when applicable) before a panniculectomy can be undertaken. If performed prematurely, there is the potential for a second panniculus to develop once additional weight loss has occurred. Expert medical opinion supports this conservative approach.

The evidence is currently insufficient to support panniculectomy as a medically beneficial procedure when the above medically necessary criteria are not met. This includes the concurrent use of panniculectomy with other abdominal surgical procedures, such as incisional or ventral hernia repair or hysterectomy, unless the criteria for panniculectomy alone are met. Although it has been suggested that the presence of a large overhanging panniculus may interfere with the surgery or compromise post-operative recovery, there is insufficient evidence to support the proposed benefits of improved surgical site access or improved health outcomes.

There is little evidence to demonstrate any significant health benefit imparted by abdominoplasty either for diastasis recti or for other indications. While there is ample literature to illustrate the cosmetic benefits of this procedure, improvements in physical functioning, cessation of back pain and other positive health outcomes have not been demonstrated. The main body of evidence is limited to individual case reports primarily concerned with the cosmetic outcomes of the surgery. At this time, there is insufficient evidence to support abdominoplasty for other than cosmetic purposes when done to remove excess abdominal skin or fat, with or without tightening lax anterior abdominal wall muscles.

Surgical procedures to correct diastasis recti have not been demonstrated to be effective for alleviating back pain or other non-cosmetic conditions. At this time, there is insufficient evidence to support the use of surgical procedures to correct diastasis recti for other than cosmetic purposes.

The use of liposuction has not been shown in clinical trials to provide additional benefits beyond standard surgical techniques and has been associated with significant complications, including some deaths.

Panniculectomy is a surgical procedure used to remove a panniculus, which is an “apron” of fat and skin that hangs from the front of the abdomen. In certain circumstances, this “apron” can be associated with skin irritation and infection due to interference with proper hygiene and constant skin-on-skin contact in the folds underneath the panniculus. The presence of a panniculus may also interfere with daily activities.

It has been proposed that for certain gynecologic or other medically necessary procedures, such as incisional or ventral hernia repair or hysterectomy, the presence of a large overhanging panniculus may interfere with the surgery or compromise post-operative recovery. Under these circumstances, it has been suggested that concurrent or adjunctive panniculectomy could be reasonable to facilitate the primary procedure. One common argument for this procedure is that the presence of a large panniculus may have negative effects on the ability of a ventral hernia repair to heal properly and may actually cause rupture of suture lines or other complications. However, there is little evidence addressing the proposed benefits of improved surgical site access or improved health outcomes as a result of the concurrent use of panniculectomy for either gynecological or abdominal procedures.

Abdominoplasty is a surgical procedure intended to remove excess skin and/or fat, and to tighten the muscles of the abdomen. The first step involves creating a horizontal incision across the lower abdomen followed by separation of the muscles from the layer of skin and fat over it. The muscles are then separated along the mid-line of the belly and brought together again in a new configuration. The layer of skin and fat is then pulled downward and the excess is removed. The navel is often re-positioned during this surgery.

Abdominoplasty may also be used to correct a condition known as diastasis recti, which is a separation between the left and right side of the rectus abdominis muscle, the muscle covering the front surface of the abdomen. This condition is frequently seen in newborns. As the infant develops, the rectus abdominis muscles continue to grow and the diastasis recti gradually disappears. Surgical treatment may be indicated if a hernia develops and becomes trapped in the space between the muscles, although this is extremely rare. Diastasis recti may also be seen in some women during or following pregnancy, especially in women with poor abdominal tone. The abdominal muscles separate because of the increasing pressure of the growing fetus. In such cases, postpartum abdominal exercises to strengthen the musculature may close the diastasis recti.

Liposuction, also known as lipoplasty or suction-assisted lipectomy, is a surgical procedure performed to recontour the patient's body by removing excess fat deposits that have been resistant to reduction by diet or exercise. This procedure has been used on various locations of the body, including the buttocks, thighs, shin and abdomen. Liposuction does not remove large quantities of fat and is not intended as a weight reduction technique.

Abdominoplasty: a procedure involving the removal of excess abdominal skin and/or fat with or without tightening lax anterior abdominal wall muscles; it may be reconstructive or cosmetic and may also be known as a tummy tuck

Bariatric surgery: a variety of surgical procedures designed to treat obesity by either reconstructing the stomach and/or intestines or placing restrictive devices in or on the digestive tract

Cellulitis: a diffuse, spreading inflammation of the deep tissues under the skin, and on occasion muscle, which may be associated with abscess formation

Diastasis recti: a condition characterized by a separation between the left and right side of the rectus abdominis, which is the muscle covering the front surface of the chest (abdomen); a diastasis recti appears as a ridge running down the midline of the abdomen from the bottom of the breastbone to the navel

Hysterectomy: surgical removal of the uterus

Incisional hernia: a condition where tissues or organs are able to push through a surgical incision or scar

Intertrigo: an inflammation of the top layers of skin caused by moisture, bacteria, or fungi in the folds of the skin

Liposuction: a surgical procedure designed to remove fat from under the skin via a suction device

Panniculectomy: a procedure designed to remove fatty tissue and excess skin (panniculus) from the lower to middle portions of the abdomen

Pubis: a part of the pelvic bone that is located in the groin; also called the pubic bone

The following codes for treatments and procedures applicable to this policy are included below for informational purposes.  Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member’s contract benefits in effect at the time of service to determine coverage or non-coverage or these services as it applies to an individual member.

When services may be Medically Necessary when criteria are met:

CPT

ICD-9 Procedure

ICD-9 Diagnosis

When services are Not Medically Necessary or Cosmetic:

For the procedure codes listed above, see policy position for instances when panniculectomy and abdominoplasty is considered not medically necessary or cosmetic.

When services are Cosmetic:

CPT

ICD-9 Diagnosis

When services are also Cosmetic:

CPT

ICD-9 Procedure

ICD-9 Diagnosis

Peer Reviewed Publications:

1. Blomfield PI, Le T, Allen DG, Planner RS.  Panniculectomy: a useful technique for the obese patient undergoing gynecological surgery. Gynecol Oncol. 1998; 70(1):80-86.
2. Cassar K, Munro A. Surgical treatment of incisional hernia. Br J Surg. 2002; 89(5):534-545.
3. Hopkins MP, Shriner AM, Parker MG, Scott L. Panniculectomy at the time of gynecologic surgery in morbidly obese patients. Am J Obstet Gynecol. 2000; 182(6):1502-1505. 
4. Hughes KC. Ventral hernia repair with simultaneous panniculectomy. Ann Surg. 1996; 62(8):678-81.
5. Matarasso A, Wallach SG, Rankin M, Galiano RD.  Secondary abdominal contour surgery: a review of early and late reoperative surgery. Plast Reconstr Surg. 2005 Feb;115(2):627-32.
6. Nahas FX, Augusto SM, Ghelfond C.  Should diastasis recti be corrected?  Aesth Plas Surg.  1997; 21:285-589.
7. Pearl ML, Valea FA, Disilvestro PA, Chalas E.  Panniculectomy in morbidly obese gynecologic oncology patients. Int J Surg Investig. 2000; 2(1):59-64.
8. Powell JL. Panniculectomy to facilitate gynecologic surgery in morbidly obese women. Obstet Gynecol. 1999 94(4):528-531.
9. Raimirez OM. Abdominoplasty and Abdominal Wall Rehabilitation: A comprehensive approach.  Plast Reconstr Surg.  2000; 105(1):425-435.
10. Sabiston: Textbook of Surgery; 15th edition, 1997 pp813.
11. Tillmanns TD, Kamelle SA, Abudayyeh I, et al.  Panniculectomy with simultaneous gynecologic oncology surgery. Gynecol Oncol. 2001; 83(3):518-522.
12. Toranto IR. The relief of low back pain with the WRAP abdominoplasty: A preliminary report. Plast Recon Surg. 1990; 85(4):545-555. 
13. Townsend: Sabiston Textbook of Surgery, 16th edition, W.B. Saunders Company, 2001. 

Government Agency, Medical Society, and Other Authoritative Publications:

1. American Society of Plastic and Reconstructive Surgeons.  Abdominoplasty: Recommended criteria for third-party payer coverage. 2005. Available at:
   http://www.plasticsurgery.org/medical_professionals/health_policy/loader.cfm?url=/commonspot/security/getfile.cfm&PageID=18092   Accessed on January 19, 2007. 
2. American Society of Plastic and Reconstructive Surgeons. Treatment of skin redundancy following massive weight loss. 2005. Available at:
   http://www.plasticsurgery.org/medical_professionals/health_policy/loader.cfm?url=/commonspot/security/getfile.cfm&PageID=18091  Accessed on  January 19, 2007. 
3. American Academy of Dermatology (AAD). Guidelines of Care for Liposuction. 2000. Available at:    http://www.aad.org/professionals/guidelines/Liposuction.htm.  Accessed on January 19, 2007.

1. National Library of Medicine. Medical Encyclopedia: Abdominoplasty - series.  Available at: http://www.nlm.nih.gov/medlineplus/ency/presentations/100184_1.htm. Accessed on January 19, 2007. 
2. National Library of Medicine. Medical Encyclopedia: Diastasis recti.  Available at:  http://www.nlm.nih.gov/medlineplus/ency/article/001602.htm. Accessed on January 19, 2007.

Abdominoplasty
Cosmetic Surgery
Diastasis Recti
Liposuction
Panniculectomy
Reconstructive Surgery

Federal and State law, as well as contract language, including definitions and specific contract provisions/exclusions, take precedence over Medical Policy and must be considered first in determining eligibility for coverage. The member's contract benefits in effect on the date that services are rendered must be used. Medical Policy, which addresses medical efficacy, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and we reserve the right to review and update Medical Policy periodically. No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by an means, electronic, mechanical, photocopying, or otherwise, without permission from the health plan.

©CPT Only - American Medical Association