Abdominoplasty and Panniculectomy*
Medical Policy: 07.01.46
Original Effective Date: December 2008
Reviewed: March 2012
Revised: October 2010
Benefit Application
Benefit determinations are based on the applicable contract language in effect at the time the
services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary
based on contract, and individual member benefits must be verified. Wellmark determines medical
necessity only if the benefit exists and no contract exclusions are applicable. This medical
policy may not apply to FEP. Benefits are determined by the Federal Employee Program.
This Medical Policy 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 will be reviewed regularly and be updated as scientific
and medical literature becomes available.
Description:
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. It is most often performed for cosmetic purposes and may be performed at the time of a panniculectomy.
Panniculectomy involves the removal of hanging excess skin and fat in a transverse or vertical wedge, but does not include muscle plication, neoumbilicoplasty or flap elevation.
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Prior Approval:
Prior approval is recommended. Submit a prior approval now
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Policy:
Panniculectomy, with or without abdominoplasty, may be considered medically necessary when the following criteria are met:
- The panniculus extends to or beyond the level of the symphysis pubis; AND
- The patient has maintained a stable weight for at least six months; AND
- Documentation by the treating clinician that the panniculus is associated with:
- evidence of recurrent non-healing ulcerations, accompanied with skin deterioration, nonresponsive to the use of oral and/or IV antibiotics OR
- recurrent episodes of a localized skin infection (with or without streaking cellulitis) that is not responding to conventional treatment for a period of 3 months; AND
- If the patient has had bariatric surgery, he/she is at least 18 months post operative
Panniculectomy, with or without abdominoplasty, is considered not medically necessary when the above criteria are not met.
Panniculectomy and abdominoplasty when associated with bariatric surgery is considered cosmetic if the above criteria are not met.
Panniculectomy, with or without abdominoplasty, may be considered medically necessary as an adjunct to a medically necessary procedure when needed for exposure in extraordinary circumstances.
Panniculectomy and abdominoplasty are considered not medically necessary when performed primarily for the treatment of neck or back pain.
Panniculectomy and abdominoplasty are considered cosmetic when performed primarily for ANY of the following:
Suction-assisted lipectomy is considered not medically necessary.
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Procedure Codes and Billing Guidelines:
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To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9-CM diagnostic codes.
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15830 Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy
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15847 Excision, excessive skin and subcutaneous tissue (includes lipectomy), abdomen (eg, abdominoplasty) (includes umbilical transposition and fascial plication) (List separately in addition to code for primary procedure)
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Selected References:
- American Society of Plastic Surgeons (ASPS). Position Paper: Abdominoplasty, Recommended Criteria for Third-Party Payer Coverage. July 2006. Updated 2007. Arlington Heights, IL. Available at: http://www.plasticsurgery.org. Accessed December 22, 2008.
- American Society of Plastic Surgeons (ASPS). Position Paper: Abdominoplasty and Panniculectomy Unrelated to Obesity or Massive Weight Loss. July 2006. Updated 2007. Arlington Heights, IL. Available at: http://plasticsurgery.org. Accessed December 22, 2008.
- American Society of Plastic Surgeons (ASPS) Position Paper: Surgical Treatment of Skin Redundancy for Obese and Massive Weight Loss Patients. July 2006. Updated 2007. Arlington Heights, IL. Available at: http://www.plasticsurgery.org. Accessed December 2008.
- Fraccalvieri M, Datta G, Bogetti P et al. Abdominoplasty after weight loss in morbidly obese patients: a 4-year clinical experience. Obes Surg. 2007 Oct; 17(10):1319-24.
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Manahan MA, Shermak MA. Massive panniculectomy after massive weight loss. Plast Reconstr Surg. 2006 Jun;117(7):2191-7; discussion 2198-9.
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Neaman KC, Hansen JE. Analysis of complications from abdominoplasty: a review of 206 cases at a university hospital. Ann Plast Surg. 2007 Mar;58(3):292-8.
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Acartuk TO, Wachtman G, Heil B et al. Panniculectomy as an adjuvant to bariatric surgery. Ann Plast Surg 2004 Oct; 53(4):360-6; discussion 367.
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Ferri F, Ferri’s Clinical Advisor 2011, 1st ed. Mosby by Elsevier,2010. Philadelphia, PA.
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Policy History:
Date Reason Action
August 2010 Clarify Redundant Policy revised
Skin Language
October 2010 Define Cellulitis and Policy revised
Ulcerations
November 2010 Criteria Clarification Policy revised
May 2011 Annual review Policy renewed
March 2012 Annual review Policy renewed
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Wellmark medical policies address the complex issue
of technology assessment of new and emerging treatments, devices,
drugs, etc. They are developed to
assist in administering plan benefits and constitute neither offers of
coverage nor medical advice. Wellmark medical policies contain only a
partial, general description of plan or program benefits and do not
constitute a contract. Wellmark does not provide health care services
and, therefore, cannot guarantee any results or outcomes.
Participating providers are independent contractors in private
practice and are neither employees nor agents of Wellmark or its
affiliates. Treating providers are solely responsible for medical
advice and treatment of members. Our medical policies may be updated
and therefore are subject to change without notice.
*Current Procedural Terminology © 2012 American Medical Association. All Rights Reserved.
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