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Abdominoplasty/panniculectomy

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan will be used to determine your coverage.

Administrative process

Prior authorization is required for abdominoplasty/panniculectomy.

Abdominoplasty/panniculectomy is generally not covered for cosmetic reasons to improve the appearance of the patient, but may be covered subject to the criteria listed below:

Indications that are covered

  1. Diastasis rectus repair: To correct the separation of the rectus muscles of the abdominal wall (diastasis rectus) when the condition is severe as measured by the following:
    1. Persistent abdominal tenderness
    2. Clinical palpation of abdominal viscera which jeopardizes function of the abdominal wall. This may include, but is not limited to, its role in posture, trunk stability, respiration and trunk flexion, rotation and side bending.
  2. Panniculectomy:
    The panniculus must hang below the level of the pubis, and all of the following criteria must be met:
    1. Chronic and recurrent skin conditions (cellulitis, skin necrosis, open areas) have failed to respond to (or be managed by) conservative medical treatment for 6 months of medically supervised therapy; and
    2. Physician visit notes are submitted indicating the nature of the skin condition, treatments attempted and the response to treatment as described above in “a”.; and
    3. Front and lateral photographs demonstrating the size of the pannus and skin condition must be submitted.
    4. Panniculectomy requests after gastric bypass surgery must meet all criteria above. In addition the member must have attained adequate weight loss and have maintained that weight loss for at least 6 months.

Indications that are not covered

  1. Abdominoplasty
  2. Any of these procedures when performed for cosmetic reasons.

Abdominoplasty is surgery performed to remove excessive fat and skin from the abdomen. It is usually performed in order to improve the appearance of the patient.

Diastasis recti abdominis is the separation of the rectus muscles of the abdominal wall, which sometimes results in herniation of the abdominal viscera and may occur during pregnancy.
 

Panniculectomy is the surgical excision of the abdominal apron of superficial fat, and may also be referred to as abdominoplasty.
 

If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.

15830 - Excision, excessive skin and subcutaneous tissue (includes lipectomy);
abdomen, infraumbilical panniculectomy
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)

CPT Copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.