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Coverage criteria policies

Panniculectomy – Minnesota Health Care Programs

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 not applicable for panniculectomy.

Prior authorization is required for abdominoplasty and diastasis recti repair.

Coverage

Panniculectomy is not a covered benefit under Minnesota Health Care Program plans.

Indications that are not covered

  1. Panniculectomy is not a covered benefit.
  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.

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

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

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.

The following CPT code is not a covered benefit under Minnesota Health Care Program plans:

Codes

Description

15830

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

The following CPT Codes are considered cosmetic and are non-covered:

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. Minnesota Health Care Programs (MHCP) Provider Manual: Covered Services Revised 9/8/2017

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Policy activity

  • 12/29/2017 - Date of origin
  • 12/29/2017 - Effective date
Review date
  • 11/2018

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