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Coverage criteria policies

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 documents will be used to determine your coverage.

Administrative Process

Prior authorization is required for panniculectomy, abdominoplasty, and diastasis recti repair.

We encourage members to check with Member Services regarding their health plan benefits for panniculectomy surgery as this service may not be covered by all plans.

Coverage

Panniculectomy surgery is generally covered subject to the indications listed below and per your plan documents.

Indications that are covered

Panniculectomy surgery may be eligible for coverage when all of the following criteria are met:

  1. There is clinical documentation of chronic or recurrent skin conditions which have developed as a result of juxtaposed folds of skin and have failed to respond to or be managed by appropriate hygiene practices as well as medical treatment for at least 6 months of medically supervised therapy. Physician visit notes must be submitted which clearly indicate the nature of the skin condition, treatments attempted, and the response to treatment over a period of at least 6 months. Applicable skin conditions include cellulitis, skin necrosis, ulcerations or open areas within skin folds.
  2. Front and lateral photographs are submitted which clearly demonstrate:
    1. A panniculus that hangs below the level of the symphysis pubis; and
    2. At least one of the associated skin conditions described above
  3. For panniculectomy requests after weight loss surgery, the member must meet all criteria above. In addition, there must be documentation that the member has achieved adequate weight loss and has maintained that weight loss for at least 6 months.

Indications that are not covered

  1. Panniculectomy is considered cosmetic if all of the criteria above are not met.
  2. Abdominoplasty is considered cosmetic.
  3. Diastasis recti (rectus diastasis) repair is considered cosmetic.

Definitions

Abdominoplasty is surgery performed to tighten a lax anterior abdominal wall and remove excessive fat and skin from the abdomen. It is also known as a “tummy tuck” and is primarily performed in order to improve the appearance of the patient.

Cellulitis is an acute spreading bacterial infection in the deeper layers of the skin (i.e. the dermis and subcutaneous tissues). It is characterized by redness, warmth, swelling, pain, fever and malaise. Cellulitis commonly appears in areas where there is a break in the skin from an abrasion, cut, or skin ulceration. Standard treatment is antibiotic therapy.

Diastasis recti (rectus diastasis) is the separation of the rectus muscles in the midline of the abdominal wall, resulting in abdominal protrusion. Diastasis recti is not considered a true hernia and does not lead to complications that require intervention.

Necrosis is the death of living cells and tissue. It is caused by localized tissue injury, such as corrosion or erosion, a lesion or ulceration, or loss of blood supply.

Panniculectomy is the surgical excision of the abdominal apron of superficial fat and skin (panniculus) without muscle resection.

Skin Ulceration is a break in the skin with an accompanying loss of surface tissue with disintegration and necrosis of underlying tissue.

Symphysis pubis is the area of the junction of the pubic bones. It lies at the center-front of the pelvic girdle.

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.

CPT Codes that may be covered when they above criteria are met:

Codes

Description

15830

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

CPT Codes that are considered cosmetic:

Codes

Description

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)

17999

Unlisted procedure, skin, mucous membrane and subcutaneous tissue (often used to report a mini-abdominoplasty)

15877

Suction assisted lipectomy; trunk (unless reported as part of an approved panniculectomy)

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.

References

  1. American Society of Plastic Surgeons (2007) Surgical Treatment of Skin Redundancy for Obese and Massive Weight Loss Patients. Accessed 11/15/16 from /www.plasticsurgery.org
  2. Akram, J. & Matzen, S. H. (2014) Rectus Abdominis distasis. Journal of Plastic Surgery and Hand Surgery, 48:3, 163-169.
  3. Hayes, Inc. Hayes Medical Technology Directory Report. Panniculectomy for Treatment of Symptomatic Panniculi. Lansdale, PA: Hayes, Inc.; May, 2016. Reviewed April, 2018.
  4. UptoDate. Nahabedian, M. & Brooks, D. Rectus Abdominis Diastasis. In: UpToDate, Butler, C. & Rosen, M. (Ed), UpToDate, Waltham, MA. (Accessed on 11/12/2018.

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Policy activity

  • 10/01/1995 - Date of origin
  • 11/01/2016 - Effective date
Review date
  • 11/2018
Revision date
  • 11/17/2016

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