Panniculectomy/Abdominoplasty

Policy Number: Original Effective Date: MM.06.010 07/15/2003 Line(s) of Business: Current Effective Date: PPO; HMO; QUEST 01/24/2014 Section: Surgery Place(s) of Service: Outpatient

I. Description Panniculectomy is the surgical resection of the overhanging "apron" of redundant skin and fat in the lower abdominal area. A panniculus is often seen in men or women who have had significant weight loss or in morbidly obese persons. The panniculus can cause difficulty fitting into clothing, interfere with personal hygiene, impair ambulation and can 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 (e.g., fungal dermatitis, folliculitis, subcutaneous abscesses) or panniculitis. Abdominoplasty is a surgical procedure which tightens a lax anterior abdominal wall caused by diastasis recti and removes excess fat and abdominal skin. This procedure, also referred to as a "tummy tuck," reduces the appearance of a protruding abdomen giving a flatter, firmer, tighter stomach and thin waist and provides an overall improvement in the person's shape and figure. Liposuction also may be performed in conjunction with a "tummy tuck" to further sculpt the abdomen or remove fat from other areas such as the hip.

II. Criteria/Guidelines A. A panniculectomy is covered (subject to Limitations/Exclusions and Administrative Guidelines) in a patient with stable weight, when any one of the following criteria is met: 1. There are recurrent documented rashes that do not respond to conventional treatment. 2. There are documented recurrent or nonhealing ulcers that do not respond to conventional treatment. 3. There is a functional impairment such as significant difficulty with walking. B. Surgical procedures for the removal of redundant skin in other areas of the body (e.g., upper arm brachioplasty, thighplasty, hip-plasty, or circumferential excision of redundant skin of trunk) must meet the same criteria for panniculectomy in order to be covered.

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III. Limitations/Exclusions An abdominoplasty or "tummy tuck" (CPT 15847 used in conjunction with CPT 15830) is considered cosmetic and not a covered benefit.

IV. Administrative Guidelines A. Precertification is required for panniculectomy. To precertify, please complete the Precertification Request and mail or fax the form as indicated. B. Front and lateral view photographs or digital images demonstrating the size of the panniculus and/or other affected body parts and the nature or extent of skin irritation, cellulitis or skin necrosis are required.

CPT Code Description 00802 Anesthesia for procedures on lower anterior abdominal wall; panniculectomy 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 19316 Mastopexy

V. Important Reminder The purpose of this Medical Policy is to provide a guide to coverage. This Medical Policy is not intended to dictate to providers how to practice medicine. Nothing in this Medical Policy is intended to discourage or prohibit providing other medical advice or treatment deemed appropriate by the treating physician. Benefit determinations are subject to applicable member contract language. To the extent there are any conflicts between these guidelines and the contract language, the contract language will control. This Medical Policy has been developed through consideration of the medical necessity criteria under Hawaii’s Patients’ Bill of Rights and Responsibilities Act (Hawaii Revised Statutes §432E-1.4), generally accepted standards of medical practice and review of medical literature Panniculectomy/Abdominoplasty 3

and government approval status. HMSA has determined that services not covered under this Medical Policy will not be medically necessary under Hawaii law in most cases. If a treating physician disagrees with HMSA’s determination as to medical necessity in a given case, the physician may request that HMSA reconsider the application of the medical necessity criteria to the case at issue in light of any supporting documentation.

VI. References 1. American Society of Plastic Surgeons. ASPS recommended insurance coverage criteria for third-party payers. Abdominoplasty and Panniculectomy Unrelated to Obesity or Massive Weight Loss, January 2007. 2. American Society of Plastic Surgeons. ASPS recommended insurance coverage criteria for third-party payers. Surgical Treatment of Skin Redundancy for Obese and Massive Weight Loss Patients, January 2007.