When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.
This Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.
Panniculectomy is a surgical procedure in which a large, redundant apron of subcutaneous fat and abdominal skin (the panniculus) is removed from the lower abdomen. This redundant apron of skin and fat is due to a lack of underlying supportive tissue and does not respond to weight loss or exercise, and can occur in people of normal weight and in morbidly obese individuals. Skin chaffing may be present under the apron, which may create an environment favorable to bacterial or fungal infections (intertrigo).
It has been proposed that for certain abdominal or gynecologic surgical procedures, including but not limited to incisional/ventral hernia repair or hysterectomy, the presence of a large overhanging panniculus may interfere with the surgery or may compromise postoperative recovery. However, adjuvant panniculectomy in most instances is not essential to improving clinical outcomes of the abdominal or gynecologic surgical procedures. In addition, available published peer-reviewed literature does not indicate that a panniculus contributes to formation of a hernia (a small sac containing tissue that protrudes through an opening in the muscles of the abdominal wall). The main cause of hernia formation is an abdominal wall weakness or defect, not a pulling effect from a redundant or large panniculus.
There are circumstances where a panniculectomy may be indicated in conjunction with other medically necessary surgical procedures. For individuals who are receiving a hysterectomy who concurrently have a large, overhanging, abdominal pannus, a panniculectomy will improve exposure of the operative field and decrease post-operative wound infections. In a person with multiple, recurrent ventral hernias with multiple surgical scars when mesh has been used in the repair, if mesh use is planned in the repair, or when a components separation procedure* is planned, a panniculectomy will remove many of the pre-existing scars which reduce ischemic skin edges and decrease the risk of skin necrosis, mesh exposure, and infection while also decreasing the amount of post-operative tension on the surgical closure. Additionally, in an individual who has a prior ostomy, an open wound(s), or exposed draining fistula(ae) from infected mesh, a panniculectomy will remove infected soft tissues, prior scars, and infected foreign body mesh that may contaminate the new abdominal wall construction.
THE FOLLOWING PROCEDURE IS CONSIDERED A COSMETIC SERVICE AND, THEREFORE, A BENEFIT CONTRACT EXCLUSION:
Policy: 11.03.02r:Bariatric Surgery
Policy: 11.08.03j:Lipectomy and Liposuction