Notification



Notification Issue Date:



Medical Policy Bulletin


Title:Panniculectomy, Abdominoplasty, and Other Excisions of Redundant Skin

Policy #:11.08.06j

This policy is applicable to the Company’s commercial products only. Policies that are applicable to the Company’s Medicare Advantage products are accessible via a separate Medicare Advantage policy database.


The Company makes decisions on coverage based on Policy Bulletins, benefit plan documents, and the member’s medical history and condition. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable.

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.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's contract. State mandates do not automatically apply to self-funded groups; therefore, individual group benefits must be verified.

MEDICALLY NECESSARY

PANNICULECTOMY
When performed as a cosmetic service, panniculectomy is a benefit contract exclusion for all products of the Company and is not eligible for reimbursement consideration. However, panniculectomy is considered medically necessary and, therefore, covered when all of the following criteria are met:
  • The panniculus (pannus) hangs to or below the level of the pubis
  • Persistent, chronic irritation and/or infection are present in the area of the hanging panniculus, along with any of the following:
    • Ulceration
    • Necrosis
    • Suprapubic intertrigo
    • Panniculitis
  • A three-month course of medical therapy has been ineffective in managing (or controlling) symptoms.
    • Examples of agents that may be used for conservative treatment are: topically applied skin barriers, supportive garments, and antifungal, antibacterial, and moisture-absorbing agents.
  • The panniculus (pannus) causes significant interference with activities of daily living (e.g., caring for areas of redundant skin and associated hygiene) or problems with ambulation.
  • If panniculectomy is performed to correct redundant tissue after massive weight loss, all of the following criteria must also be met:
    • Stable weight is maintained for at least six months.
    • If the individual has had bariatric surgery, panniculectomy should not be performed until at least 24 months after the bariatric surgery.

PANNICULECTOMY PERFORMED ON THE SAME DAY IN CONJUNCTION WITH OTHER MEDICALLY NECESSARY PROCEDURES TO OBTAIN AN ACCESSIBLE SURGICAL SITE
There are limited, exceptional clinical circumstances when a panniculectomy performed on the same day in conjunction with another medically necessary procedure to obtain an accessible surgical site is also medically necessary and, therefore, covered when any of the respective criteria below are met.
  • Hysterectomy in individuals with a significant panniculus
  • In individuals with multiple, recurrent ventral hernias with multiple surgical scars when mesh has been utilized or will be utilized for repair or when a components separation procedure is anticipated in the surgical plan
  • Abdominal surgery with the presence of a prior ostomy, open wounds, or exposed draining fistula(ae) from infected mesh

EXCISIONS OF REDUNDANT SKIN OTHER THAN ABDOMEN/PANNUS
When performed as a cosmetic service, excision of redundant skin is a benefit contract exclusion for all products of the Company and is not eligible for reimbursement consideration. However, excision of redundant skin is considered medically necessary and, therefore, covered when all of the following criteria are met:
  • Persistent, chronic irritation and/or infection are present in the area of the redundant skin, along with any of the following:
    • Ulceration
    • Necrosis
    • Intertrigo
  • A three-month course of medical therapy has been ineffective in managing (or controlling) symptoms.
    • Examples of agents that may be used for conservative treatment are topically applied skin barriers; supportive garments; and antifungal, antibacterial, and moisture-absorbing agents.
  • The redundant skin causes significant interference with activities of daily living (e.g., caring for areas of redundant skin and associated hygiene) or problems with ambulation.
  • If excision of redundant skin is performed to correct redundant tissue after massive weight loss, all of the following criteria must also be met:
    • Stable weight is maintained for at least six months.
    • If the individual has had bariatric surgery, excision of redundant skin should not be performed until at least 24 months after the bariatric surgery.

COSMETIC

PANNICULECTOMY
If the criteria for panniculectomy or panniculectomy performed on the same day in conjunction with other medically necessary procedures is not met, panniculectomy is a considered cosmetic service.
Services that are cosmetic are a benefit contract exclusion for all products of the Company. Therefore, they are not eligible for reimbursement consideration.

EXCISION OF REDUNDANT SKIN OTHER THAN ABDOMEN/PANNUS
If the criteria for excision of redundant skin is not met, excision of redundant skin is considered a cosmetic service. Services that are cosmetic are a benefit contract exclusion for all products of the Company. Therefore, they are not eligible for reimbursement consideration.

ABDOMINOPLASTY
Abdominoplasty performed to remove excess skin and fat and to tighten the fascia of the abdominal wall is not covered by the Company because it is considered a cosmetic service. Services that are cosmetic are a benefit contract exclusion for all products of the Company. Therefore, they are not eligible for reimbursement consideration.

DIASTASIS RECTI REPAIR
Diastasis recti repair performed to tighten the fascia of the abdominal wall is not covered by the Company because it is considered a cosmetic service. Services that are cosmetic are a benefit contract exclusion for all products of the Company. Therefore, they are not eligible for reimbursement consideration.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.

All requests for the procedures mentioned in this policy require a review by the Company and must include all of the following:
  • Dated photographs of the panniculus hanging over the pubis and of the panniculus or redundant skin elevated to expose the chronic, persistent, and refractory skin infection or irritation. chronic, persistent, and refractory skin infection or irritation.
  • Office notes from the treating professional provider that reflect the chronic, persistent, and refractory skin infection and/or irritation, despite optimal medical care over a three-month period.
  • A listing of the medications that were used to treat the chronic skin infection or irritation during the three-month period and the length of time that the medications were used.
  • Documentation when applicable, that demonstrates massive weight loss, weight stability, and date of bariatric surgery.

Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, panniculectomy and other excisions of redundant skin are covered under the medical benefits of the Company's products when all of the medical necessity criteria in the medical policy are met.

Services that are cosmetic are a benefit contract exclusion for all products of the Company. Therefore, they are not eligible for reimbursement consideration.

Description

PANNICULECTOMY


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 Component Separation Technique (CST) is a type of rectus abdominis muscle advancement flap. It was first used to reconstitute the linea alba, reduce abdominal wall tension, and provide a dynamic abdominal wall in persons with large abdominal wall defects. This technique allows reconstruction of a large defect without requiring a free distant transposition flap. The advantages of CST are that it restores structural support of the abdominal wall, provides stable soft tissue coverage, and optimizes esthetic appearance of complex abdominal wall defects and giant midline abdominal wall hernias.

Panniculectomy may be performed to correct the redundant tissue that occurs in obese individuals after massive weight loss resulting from various regimens such as bariatric surgery. After these individuals experience massive weight loss, many are left with a redundant panniculus that poses a risk for a panniculus bacterial or fungal infection. Weight stability is required before panniculectomy because there is potential for development of another panniculus if additional weight loss occurs, thus increasing the risk of postoperative complications.

ABDOMINOPLASTY

Abdominoplasty is a surgical procedure that is performed to tighten a lax abdominal wall. It involves the removal of excess skin and fat from the middle and lower abdomen: the skin is pulled downward, and the underlying fascia (dense connective tissue that surrounds the muscles) is tightened. This procedure may also include reimplantation of the umbilicus. During an abdominoplasty procedure, a large incision is made across the lower abdomen, and the skin is separated from the abdominal wall up to the ribs. According to the American Society of Plastic Surgeons (ASPS), abdominoplasty is typically performed for cosmetic purposes.

An abdominal wall weakness or defect is also evident in diastasis recti. The main musculature of the abdomen is held together at the anterior midline by a long, triangular structure called the linea alba. The linea alba's insertion is at the xiphoid process of the sternum and extends downward to the pubis. According to medical literature, the condition of diastasis recti presents as a weakness or laxity of the abdominal wall, including the linea alba, but does not constitute a true hernia and is of no clinical significance.

EXCISIONS OF REDUNDANT SKIN OTHER THAN ABDOMEN/PANNUS

Extensive redundancy of skin and fat folds can also appear in areas such as the medial aspect of the upper arms, breasts, buttocks, and thighs, and may create environments that are susceptible to skin infection. Fungal dermatitis, bacterial or monilial infection, and/or panniculitis, collectively called "intertrigo," can occur. Medical management by the application of skin barriers, moisture-absorbing agents, and/or the use of supportive garments is indicated as the first line of treatment. However, if the condition is persistent and remains refractory to medical treatment, improvement may be achieved by surgical intervention. Excessive skin and fat are excised using appropriate incisions and techniques that allow for the direct removal of the redundant skin, with the subsequent approximation and suturing of the remaining skin.

In recent years, the surgical correction of morbid obesity and/or stringent diet regimens have assisted many individuals in achieving and sustaining weight loss. Although the benefits of weight loss are obvious, problems that are secondary to weight loss may appear, including skin redundancy with folds of skin and/or fat that are prone to infection. In addition, the aging process itself causes the underlying supportive structures of the skin to sag, which often creates skin redundancy.

COSMETIC

There may be times when panniculectomy, and other excisions of redundant skin are performed for cosmetic purposes. Cosmetic services are those provided to improve an individual's physical appearance, from which no significant improvement in physiologic function can be expected. Emotional and/or psychological improvement alone does not constitute improvement in physiologic function.
References


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American Society of Plastic Surgeons (ASPS). ASPS Recommended Insurance Coverage Criteria for Third-Party Payers. Abdominoplasty and Panniculectomy Unrelated to Obesity or Massive Weight Loss. [ASPS Web site]. 01/01/2007. Available at:
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American Society of Plastic Surgeons (ASPS). ASPS recommended insurance coverage criteria for third-party payers. Surgical treatment of skin redundancy for obese and massive weight loss patients. [ASPS Web site]. January 2007. Available at: http://www.plasticsurgery.org/Documents/medical-professionals/health-policy/insurance/Surgical-Treatment-of-Skin-Redundancy-Following.pdf. Accessed August 10, 2018.

American Society of Plastic Surgeons (ASPS). Practice parameter for surgical treatment of skin redundancy for obese and massive weight loss patients. [ASPS Web site]. January 2007. Available at:http://www.plasticsurgery.org/Documents/medical-professionals/health-policy/evidence-practice/AbdominoplastyAndPanniculectomy.pdf. Accessed August 16, 2018.

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Core GB, Mizgala CL, Bowen JC 3rd, Vasconez LO. Endoscopic abdominoplasty with repair of diastasis recti and abdominal wall hernia. Clin Plast Surg. 1995;22(4):707-722.

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Gmür RU, Banic A, Erni D. Is it safe to combine abdominoplasty with other dermolipectomy procedures to correct skin excess after weight loss? Ann Plast Surg. 2003;51(4):353-357.

Hughes KC, Weider L, Fischer J, et al. Ventral hernia repair with simultaneous panniculectomy. Am Surg. 1996;62(8):678-681.

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Mechanick JI, Youdim A, Jones DB, Garvey WT et al. Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient —2013 update: cosponsored by American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery. Available at: https://www.aace.com/files/publish-ahead-of-print-final-version.pdf. Accessed August 16, 2018.

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Raftopoulos I, Vanuno D, Khorsand J, et al. Outcome of laparoscopic ventral hernia repair in correlation with obesity, type of hernia and hernia size. J Laparoendosc Adv Surg Tech A. 2002;12(6):425-429.

Ramirez OM. Abdominoplasty and abdominal wall rehabilitation: a comprehensive approach. Plast Reconstr Surg. 2000;105(1):425-435.

Rasmussen R, Patibandla JR, Hopkins MP. Evaluation of indicated non-cosmetic panniculectomy at time of gynecologic surgery. Int J Gynecol Obstet. 2017;138:207-211. Also available on the Pub Med Web site at: https://www.ncbi.nlm.nih.gov/pubmed/?term=10.1002%2Fijgo.12207. Accessed August 13, 2018.

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Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

15830, 15832, 15833, 15834, 15835, 15836, 15837, 15838, 15839


THE FOLLOWING PROCEDURE IS CONSIDERED A COSMETIC SERVICE AND, THEREFORE, A BENEFIT CONTRACT EXCLUSION:

15847



Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

See Attachment A




HCPCS Level II Code Number(s)

N/A


Revenue Code Number(s)

N/A

Coding and Billing Requirements


Cross References

Attachment A: Panniculectomy, Abdominoplasty, and Other Excisions of Redundant Skin
Description: ICD 10 codes for Abdominoplasty and/or Panniculectomy policy




Policy History

10/01/2018Inclusion of a policy in a Code Update memo does not imply that a full review of
the policy was completed at this time.

This policy has been identified for the ICD-10 CM code update, effective 10/01/2018.

The following ICD-10 CM narratives have been revised in this policy:

L98.495, L98.496, L98.498
Version Effective Date: 10/01/2018
Version Issued Date: 10/01/2018
Version Reissued Date: N/A

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