Medical Policy

 

Subject: Panniculectomy and Abdominoplasty
Document #: SURG.00048 Publish Date:    04/25/2018
Status: Reviewed Last Review Date:    03/22/2018

Description/Scope

This document addresses the surgical procedures panniculectomy and abdominoplasty and when they are considered medically necessary, not medically necessary, and cosmetic.

Medically Necessary: In this document, procedures are considered medically necessary if there is a significant physical functional impairment AND the procedure can be reasonably expected to improve the physical functional impairment.

Cosmetic: In this document, procedures are considered cosmetic when intended to change a physical appearance that would be considered within normal human anatomic variation. Cosmetic services are often described as those that are primarily intended to preserve or improve appearance. 

Position Statement

Medically Necessary:

  1. Panniculectomy is considered medically necessary for the individual who meets the following criteria:
    1. The panniculus hangs below the level of the pubis (which is documented in photographs); and
    2. One of the following:
      1. there are documented recurrent or chronic rashes, infections, cellulitis, or non-healing ulcers, that do not respond to conventional treatment (for example, dressing changes; topical, oral or systemic antibiotics, corticosteroids or antifungals) for a period of 3 months; or
      2. there is documented difficulty with ambulation and interference with the activities of daily living;
        and
    3. Symptoms or functional impairment persists despite significant* weight loss which has been stable for at least 3 months or well-documented attempts at weight loss (medically supervised diet or bariatric surgery) have been unsuccessful; and
    4. If the individual has had bariatric surgery, he/she is at least 18 months post-operative or has documented stable weight for at least 3 months.
      *Significant weight loss varies based on the individual clinical circumstances and may be documented when the individual:
      1. Reaches a body mass index (BMI) less than or equal to 30 kg/m2; or
      2. Has documented at least a 100 pound weight loss; or
      3. Has achieved a weight loss which is 40% or greater of the excess body weight that was present prior to the individual’s weight loss program or surgical intervention.
  2. Panniculectomy is considered medically necessary as an adjunct to a medically necessary surgery when needed for exposure in extraordinary circumstances.

Not Medically Necessary:

  1. Panniculectomy is considered not medically necessary when the criteria above are not met.
  2. Panniculectomy is considered not medically necessary as an adjunct to other medically necessary procedures, including, but not limited to, hysterectomy, or incisional or ventral hernia repair unless the criteria above are met.
  3. Panniculectomy or abdominoplasty, with or without diastasis recti repair, for the treatment of back pain is considered not medically necessary. 

Cosmetic and Not Medically Necessary:

  1. Liposuction is considered cosmetic and not medically necessary for all indications.
  2. Abdominoplasty when done to remove excess skin or fat with or without tightening of the underlying muscles is considered cosmetic and not medically necessary.
  3. Repair of diastasis recti is considered cosmetic and not medically necessary for all indications.
Rationale

Panniculectomy

The current medical evidence addressing the efficacy of panniculectomy consists mostly of individual case reports and review articles. The evidence base includes a limited number of small controlled trials. However, there is adequate clinical opinion to support the use of this procedure in some circumstances where an individual’s health is compromised.

Early studies by Matory (1994) and Vastine (1999) demonstrated a direct relationship between BMI and operative risk with abdominal surgery and abdominoplasty in obese individuals. In a retrospective cohort series of individuals who underwent post-bariatric panniculectomy (n=126), the only factor that independently predicted postoperative complications after panniculectomy was pre-panniculectomy BMI (Arthurs, 2007). Those with a BMI greater than 25 kg/m2 were at nearly three times the risk of postoperative wound complications. Although those who experienced a plateau in weight loss at a BMI of 30-35 kg/m2 did have the largest functional improvement from a panniculectomy, they also experienced the highest risk postoperatively. The average weight loss following bariatric surgery prior to panniculectomy was 116 ± 35 lbs. A limitation of this study was its retrospective design and small sample size.

Acarturk (2004) compared the surgical outcomes of panniculectomy following bariatric surgery in another retrospective series of 123 participants (mean age 44.5 years). The outcomes of 21 participants with panniculectomy performed at the time of bariatric surgery were compared with the surgical outcomes of 102 participants who waited 17 ± 11 months to undergo panniculectomy. Overall, individuals who had panniculectomy simultaneously with bariatric surgery experienced more complications. Wound infections were 48% versus 16%; wound dehiscence 33% versus 13%; and there was a higher incidence (24% versus 0 %) of postoperative respiratory distress in individuals with the combined procedures. There were 3 postoperative deaths in the combined procedure cohort and none in the group that delayed panniculectomy until an average weight loss of 126 ± 59 lbs was achieved. The authors concluded that an initial period of substantial weight loss prior to the procedure results in a safer and more effective panniculectomy procedure.

The American Society of Plastic Surgeons (ASPS) Practice Parameter for Surgical Treatment of Skin Redundancy for Obese and Massive Weight Loss Patients (2007b) recommends that body contouring surgery, including panniculectomy, be performed only after an individual maintains a stable weight for 2 to 6 months. For individuals who are post-bariatric surgery, this is reported to occur 12-18 months after surgery when the BMI has reached the 25 kg/m2 to 30 kg/m2 range (Rubin, 2004). If performed prematurely, a potential exists for a second panniculus to develop once additional weight loss has occurred and the risks of postoperative complications are increased. Weight loss and BMI are important when considering panniculectomy and a significant amount of weight loss may not bring the BMI of an individual to less than 30 kg/m2; however a panniculectomy may still be necessary (Arthurs, 2007). The American Society for Metabolic and Bariatric Surgery Consensus statement states weight loss can vary from about 25% to 70% of an individual’s excess body weight depending on the type of bariatric surgery that is performed (Buchwald, 2005).

Evidence is insufficient to support panniculectomy as a medically beneficial procedure when the above medically necessary criteria are not met. This includes the concurrent use of panniculectomy with other abdominal surgical procedures, such as incisional or ventral hernia repair, or hysterectomy, unless the criteria for panniculectomy alone are met. Although it has been suggested that the presence of a large overhanging panniculus may interfere with the surgery or compromise post-operative recovery, there is insufficient evidence to support the proposed benefits of improved surgical site access or improved health outcomes.

A study by Zemlyak and colleagues (2012) reported on a retrospective review of individuals who had panniculectomy alone versus individuals who had panniculectomy and simultaneous ventral hernia repair. There were 143 participants in the panniculectomy/ventral hernia repair group and 42 participants in the panniculectomy group. The rates for incisional complications and interventions between the two groups were not statistically significant. However, after controlling for age, gender, BMI, subcutaneous use of talc, and intraoperative pulse-a-vac irrigation in the multivariate regression analysis, the group that had both panniculectomy and ventral hernia repair was more likely to develop wound cellulitis. The authors note that while panniculectomy with ventral hernia repair reduces the stress on the hernia repair and potentially decreases the recurrence rate, this potential advantage remains to be proven in large comparative studies.

Fischer and colleagues (2014) conducted a large retrospective database analysis to assess the additional risk of ventral hernia repair (VHR) and panniculectomy (PAN) compared with hernia repair alone (n=55,537) using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) data sets. To account for potential selection bias given the non-randomized assignment of concurrent panniculectomy and the retrospective study design, propensity scores were used which yielded two comparable groups, VHR (n=1250) and VHR+PAN (n=1250). The study authors found that individuals who underwent the combined procedure were at significantly higher risk for wound complications (p<0.001), venous thromboembolism (p=0.044), reoperation (p<0.001) and overall medical morbidity (p<0.001). Two notable limitations of this study include that the ACS-NSQIP dataset only includes 30-day outcomes, precluding analysis of long-term differences in the two study groups. Secondly, the dataset did not include details on the type of panniculectomy skin resection or wound closure techniques, therefore propensity matching and exploratory analysis of these potentially confounding variables was not possible. Nonetheless, at 30 day follow-up in this large retrospective cohort, outcomes of panniculectomy performed with a concurrent ventral hernia repair appear to result in a significant increase in morbidity compared to VHR alone.

Giordano and colleagues (2017) published a retrospective study based on a prospectively maintained database of all consecutive midline abdominal wall reconstructions for an abdominal wall hernia or oncologic defect performed at a single site from 2005-2015. Of 548 consecutive surgeries, 305 individuals (56%) underwent abdominal wall reconstruction alone and 243 (44%) underwent abdominal wall reconstruction with concurrent panniculectomy. The mean follow-up period was 30 months. Prior to propensity matching, individuals with the combined procedure also had a higher number of previous abdominal surgeries and a larger mean abdominal wall defect size. After propensity matching, there were significantly higher incidences of fat necrosis, and surgical site abscess but no significant difference in hernia recurrence at follow-up. Abdominal wall reconstruction with concurrent panniculectomy was associated with higher wound morbidity with no difference in hernia recurrence rates in follow-up.

Abdominoplasty

There is little evidence to demonstrate significant health benefit imparted by abdominoplasty either for diastasis recti or for other indications. While there is ample literature to illustrate the cosmetic benefits of this procedure, improvements in physical functioning, cessation of back pain, and other positive health outcomes have not been demonstrated. The main body of evidence is limited to individual case reports evaluating the cosmetic outcomes of the surgery. Carloni and colleagues conducted a systematic-review (2016) and confirmed that the quality of evidence surrounding abdominoplasty remains low and no standardization of surgical approaches has been established. Winocour (2015) reported results of a study which included 25,478 abdominoplasties and found high complication rates, compared to other cosmetic procedures, especially when abdominoplasty was combined with other procedures. Massenburg (2015) reported outcomes from 2946 abdominoplasties and found 8.5% of subjects were readmitted due to complications and 5% required revision surgery. At this time, there is insufficient evidence to support abdominoplasty for any indication other than cosmetic purposes when done to remove excess abdominal skin or fat, with or without tightening lax anterior abdominal wall muscles (ASPS Practice Parameter, 2007b).

Surgical procedures to correct diastasis recti are not effective for alleviating back pain or other non-cosmetic conditions. There is insufficient evidence to support the use of surgical procedures to correct diastasis recti for other than cosmetic purposes.

The use of liposuction has not been shown in clinical trials to provide additional benefits beyond standard surgical techniques and has been associated with significant complications, including death.

Background/Overview

Obesity has been defined by BMI, obtained by dividing the weight in kilograms by height in meters squared (kg/m2). The clinical definition of obesity is BMI that is greater than 30 kg/m2, severe obesity is BMI that is greater than 35 kg/m2, and morbid obesity is BMI that is greater than 40 kg/m2. Bariatric surgery is an effective and relatively safe treatment for morbid obesity. Many individuals who are post-bariatric surgery seek consultation with a plastic surgeon for skin laxity after weight loss. Panniculectomy is a surgical procedure used to remove a panniculus, which is an “apron” of fat and skin that hangs from the front of the abdomen. In certain circumstances, this “apron” can be associated with skin irritation and infection due to interference with proper hygiene and constant skin-on-skin contact in the skin folds underneath the panniculus. The presence of a panniculus may also interfere with daily activities.

It has been proposed that for certain gynecologic or other medically necessary procedures, such as incisional or ventral hernia repair or hysterectomy, the presence of a large overhanging panniculus may interfere with the surgery or compromise post-operative recovery. Under these circumstances, it has been suggested that concurrent or adjunctive panniculectomy may be reasonable to facilitate the primary procedure. One common argument for this procedure is that the presence of a large panniculus may have negative effects on the ability of a ventral hernia repair to heal properly and may actually cause rupture of suture lines or other complications. However, there is little evidence addressing the proposed benefits of improved surgical site access or improved health outcomes as a result of the concurrent use of panniculectomy for either gynecological or abdominal procedures.

There are similarities between an abdominoplasty and a panniculectomy since both procedures remove varying amounts of abdominal wall skin and fat. Abdominoplasty, typically performed for cosmetic purposes, involves the removal of excess skin and fat from the pubis to the umbilicus or above, and may include tightening of the rectus muscle and creation or transposition of the umbilicus (navel). “Mini” or “modified” abdominoplasties are cosmetic procedures typically performed on individuals with minimal to moderate defect, mild to moderate skin laxity and muscle flaccidity, and do not involve muscle tightening above the navel, or creation of a new navel.

Abdominoplasty is also used to correct a condition known as diastasis recti, which is a separation between the left and right side of the rectus abdominis muscle, the muscle covering the front surface of the abdomen. This condition is frequently seen in newborns. As the infant develops, the rectus abdominis muscles continue to grow and the diastasis recti gradually disappear. Surgical treatment may be indicated if a hernia develops and becomes trapped in the space between the muscles, although this is extremely rare. Diastasis recti may also be seen in some women during or following pregnancy, especially in women with poor abdominal tone. The abdominal muscles separate because of the increasing pressure of the growing fetus. In such cases, postpartum abdominal exercises to strengthen the musculature may close the diastasis recti.

Liposuction, also known as lipoplasty or suction-assisted lipectomy, is a surgical procedure performed to recontour the body by removing excess fat deposits that have been resistant to reduction by diet or exercise. This procedure has been used on various locations of the body, including the buttocks, thighs, shin, and abdomen. Liposuction does not remove large quantities of fat and is not intended as a weight reduction technique.

Definitions

Abdominoplasty: A procedure involving the removal of excess abdominal skin and fat with or without tightening lax anterior abdominal wall muscles and with or without repositioning or reconstruction of the navel.

Bariatric surgery: A variety of surgical procedures designed to treat obesity by either reconstructing the stomach or intestines or placing restrictive devices in or on the digestive tract.

Cellulitis: A diffuse, spreading inflammation of the deep tissues under the skin, and on occasion muscle, which may be associated with abscess formation.

Diastasis recti: A condition characterized by a separation between the left and right side of the rectus abdominis, which is the muscle covering the front surface of the chest (abdomen). A diastasis recti appears as a ridge running down the midline of the abdomen from the bottom of the breastbone to the navel.

Hysterectomy: Surgical removal of the uterus.

Incisional hernia: A condition where tissues or organs are able to push through a surgical incision or scar.

Intertrigo: An inflammation of the top layers of skin caused by moisture, bacteria, or fungi in the folds of the skin.

Liposuction: A surgical procedure designed to remove fat from under the skin via a suction device.

Panniculectomy: A procedure designed to remove fatty tissue and excess skin (panniculus) from the lower to middle portions of the abdomen.

Pubis: A part of the pelvic bone that is located in the groin, also called the pubic bone.

Coding

The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member’s contract benefits in effect at the time of service to determine coverage or non-coverage or these services as it applies to an individual member.

Panniculectomy
When services may be Medically Necessary when criteria are met for panniculectomy:

CPT

 

00802

Anesthesia for procedures on lower anterior abdominal wall; panniculectomy

15830

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

 

 

ICD-10 Procedure

 

 

For the following codes when described as panniculectomy:

0HB7XZZ

Excision of abdomen skin, external approach

0J080ZZ

Alteration of abdomen subcutaneous tissue and fascia, open approach

0WBF0ZZ

Excision of abdominal wall, open approach

 

 

ICD-10 Diagnosis

 

 

All diagnoses

When services are Not Medically Necessary or Cosmetic and Not Medically Necessary:
For the procedure codes listed above, when the Position Statement indicates that panniculectomy is considered not medically necessary or cosmetic and not medically necessary.

Abdominoplasty, liposuction
When services are Not Medically Necessary or Cosmetic and Not Medically Necessary:
When the code describes a procedure indicated in the Position Statement section as not medically necessary or cosmetic and not medically necessary.

CPT

 

15847

Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen (eg, abdominoplasty) (includes umbilical transposition and fascial plication)

15877

Suction assisted lipectomy; trunk [when specified as abdominal liposuction]

17999

Unlisted procedure, skin, mucous membrane and subcutaneous tissue [when specified as other abdominoplasty, excision excessive skin and subcutaneous tissue, including lipectomy, of abdomen]

 

 

ICD-10 Procedure

 

0J080ZZ

Alteration of abdomen subcutaneous tissue and fascia, open approach [when specified as other abdominoplasty, excision excessive skin and subcutaneous tissue, including lipectomy]

0J083ZZ

Alteration of abdomen subcutaneous tissue and fascia, percutaneous approach

0W0F07Z-0W0F0ZZ

Alteration of abdominal wall with/without tissue substitute, open approach [ includes codes 0W0F07Z, 0W0F0JZ, 0W0F0KZ, 0W0F0ZZ]

0W0F37Z-0W0F3ZZ

Alteration of abdominal wall with/without tissue substitute, percutaneous approach [includes codes 0W0F37Z, 0W0F3JZ, 0W0F3KZ, 0W0F3ZZ]

0W0F47Z-0W0F4ZZ

Alteration of abdominal wall with/without tissue substitute, percutaneous endoscopic approach [includes codes 0W0F47Z, 0W0F4JZ, 0W0F4KZ, 0W0F4ZZ]

 

 

ICD-10 Diagnosis

 

 

All diagnoses

Repair of diastasis recti
When services are Cosmetic and Not Medically Necessary:
When the code describes a procedure indicated in the Position Statement section as cosmetic and not medically necessary.

CPT

 

22999

Unlisted procedure, abdomen, musculoskeletal system [when specified as repair of diastasis recti]

 

 

ICD-10 Procedure

 

0KQK0ZZ-0KQK4ZZ

Repair right abdomen muscle [by approach; includes codes 0KQK0ZZ, 0KQK3ZZ, 0KQK4ZZ]

0KQL0ZZ-0KQL4ZZ

Repair left abdomen muscle [by approach; includes codes 0KQL0ZZ, 0KQL3ZZ, 0KQL4ZZ]

 

 

ICD-10 Diagnosis

 

 

For the following diagnoses when specified as diastasis recti:

M62.00

Separation of muscle (nontraumatic), unspecified site

M62.08

Separation of muscle (nontraumatic), other site

O71.89

Other specified obstetric trauma

Q79.59

Other congenital malformations of abdominal wall

References

Peer Reviewed Publications:

  1. Acarturk TO, Wachtman G, Heil B, et al. Panniculectomy as an adjuvant to bariatric surgery. Ann Plast Surg. 2004; 53(4):360-366.
  2. Arthurs ZM, Cuadrado D, Sohn V, et al. Post-bariatric panniculectomy: pre-panniculectomy body mass index impacts the complication profile. Am J Surg. 2007; 193(5):567-570.
  3. Blomfield PI, Le T, Allen DG, Planner RS. Panniculectomy: a useful technique for the obese patient undergoing gynecological surgery. Gynecol Oncol. 1998; 70(1):80-86.
  4. Carloni R, De Runz, Chaput B et al. Circumferential contouring of the lower trunk: indications, operative techniques, and outcomes-a systematic review. Aesthetic Plast Surg. 2016; 40(5):652-668.
  5. Cassar K, Munro A. Surgical treatment of incisional hernia. Br J Surg. 2002; 89(5):534-545.
  6. Coriddi MR, Koltz PF, Chen R, Gusenoff JA. Changes in quality of life and functional status following abdominal contouring in the massive weight loss population. Plast Reconstr Surg. 2011; 128(2):520-526.
  7. Fischer JP, Tuggle CT, Wes AM, Lovach SJ. Concurrent panniculectomy with open ventral hernia repair has added risk versus ventral hernia repair:  an analysis of the ACS-NSQIP database. J Plast Recontr Aesthet Surg. 2014; 67(5):693-701.
  8. Giordano S, Garvey PB, Baumann DP, et al. Concomitant panniculectomy affects wound morbidity but not hernia recurrence rates in abdominal wall reconstruction: A propensity score analysis. Plast Reconstr Surg. 2017; 140(6):1263-1273.
  9. Harth KC, Blatnik JA, Rosen MJ. Optimum repair for massive ventral hernias in the morbidly obese patient--is panniculectomy helpful? Am J Surg. 2011; 201(3):396-400.
  10. Hopkins MP, Shriner AM, Parker MG, Scott L. Panniculectomy at the time of gynecologic surgery in morbidly obese patients. Am J Obstet Gynecol. 2000; 182(6):1502-1505.
  11. Hughes KC. Ventral hernia repair with simultaneous panniculectomy. Ann Surg. 1996; 62(8):678-681.
  12. Massenburg BB, Sanati-Mehrizy P, Jablonka EM, Taub PJ. Risk factors for readmission and adverse outcomes in abdominoplasty. Plast Reconstr Surg. 2015; 136(5):968-977.
  13. Matarasso A, Wallach SG, Rankin M, Galiano RD. Secondary abdominal contour surgery: a review of early and late reoperative surgery. Plast Reconstr Surg. 2005; 115(2):627-632.
  14. Matory WE, O’Sullivan J, Fudem G, Dunn R. Abdominal surgery in patients with severe morbid obesity. Plast Reconstr Surg. 1994; 94(7):976-987.
  15. Nahas FX, Augusto SM, Ghelfond C. Should diastasis recti be corrected? Aesth Plas Surg. 1997; 21(4):285-289.
  16. Pearl ML, Valea FA, Disilvestro PA, Chalas E. Panniculectomy in morbidly obese gynecologic oncology patients. Int J Surg Investig. 2000; 2(1):59-64.
  17. Powell JL. Panniculectomy to facilitate gynecologic surgery in morbidly obese women. Obstet Gynecol. 1999 94(4):528-531.
  18. Rubin JP, Nguyen V, Schwentker A. Perioperative management of the post-gastric-bypass patient presenting for body contour surgery. Clin Plast Surg. 2004; 31(4):601-610.
  19. Staalesen T, Olsén MF, Elander A. The effect of abdominoplasty and outcome of rectus fascia plication on health-related quality of life in post-bariatric surgery patients. Plast Reconstr Surg. 2015; 136(6):750e-761e.
  20. Tillmanns TD, Kamelle SA, Abudayyeh I, et al. Panniculectomy with simultaneous gynecologic oncology surgery. Gynecol Oncol. 2001; 83(3):518-522.
  21. Vastine VL, Morgan RF, Williams GS, et al. Wound complications of abdominoplasty in obese patients. Plast Surg. 1999; 42(1):34-39. 
  22. Warren JA, Epps M, Debrux C, et al. Surgical site occurrences of simultaneous panniculectomy and incisional hernia repair. Am Surg. 2015 Aug;81(8):764-769.
  23. Winocour J, Gupta V, Ramirez JR, et al. Abdominoplasty: risk factors, complication rates, and safety of combined procedures. Plast Reconstr Surg. 2015; 136(5):597e-606e.
  24. Zannis J, Wood BC, Griffin LP, et al. Outcome study of the surgical management of panniculitis. Ann Plast Surg. 2012; 68(2):194-197.
  25. Zemlyak AY, Colavita PD, El Djouzi S, et al. Comparative study of wound complications: isolated panniculectomy versus panniculectomy combined with ventral hernia repair. J Surg Res. 2012; 177(2):387-391.

Government Agency, Medical Society, and Other Authoritative Publications:

  1. American Society of Plastic and Reconstructive Surgeons (ASPS). ASPS recommended insurance coverage criteria for third-party payers: Surgical treatment of skin redundancy for obese and massive weight loss patients. 2007a. Available at: http://www.plasticsurgery.org/Medical_Professionals/Health_Policy_and_Advocacy/Health_Policy_Resources/Recommended_Insurance_Coverage_Criteria.html. Accessed on February 19, 2018.
  2. American Society of Plastic and Reconstructive Surgeons (ASPS). Practice parameter for surgical treatment of skin redundancy for obese and massive weight loss patients. 2007b. Available at: http://www.plasticsurgery.org/Documents/medical-professionals/health-policy/evidence-practice/Surgical-Treatment-of-Skin-Redundancy-Following-Massive-Weight-Loss.pdf. Accessed on February 19, 2018.  
  1. Buchwald H; Consensus Conference Panel. Consensus conference statement bariatric surgery for morbid obesity: health implications for patients, health professionals, and third-party payers. Surg Obes Relat Dis. 2005; 1(3):371-381.
  2. Coleman WP, Glogau RG, Klein JA, et al. American Academy of Dermatology Guidelines/Outcomes Committee. Guidelines of care for liposuction. J Am Acad Dermatol. 2001; 45(3):438-447.
Websites for Additional Information
  1. American Society of Plastic and Reconstructive Surgeons (ASPS). Body contouring surgical procedures physician’s guide: Panniculectomy (in obese patients). 2018. Available at: https://www.plasticsurgery.org/for-medical-professionals/resources-and-education/publications/physicians-guide-to-cosmetic-surgery/body-contouring-surgical-procedures-physician%E2%80%99s-guide?sub=Panniculectomy+(in+obese+patients). Accessed on February 19, 2018. 
  2. American Society of Plastic and Reconstructive Surgeons (ASPS). Body contouring surgical procedures physician’s guide: Tummy tuck (abdominoplasty). 2018. Available at: https://www.plasticsurgery.org/for-medical-professionals/resources-and-education/publications/physicians-guide-to-cosmetic-surgery/body-contouring-surgical-procedures-physician%E2%80%99s-guide?sub=Tummy+Tuck+(Abdominoplasty). Accessed on February 19, 2018. 
  3. National Institutes of Health. National Heart, Lung, and Blood Institute. BMI calculator. Available at: http://www.nhlbi.nih.gov/guidelines/obesity/BMI/bmicalc.htm. Accessed on February 19, 2018.
  4. National Library of Medicine. Medical Encyclopedia: Abdominoplasty - series. Available at: http://www.nlm.nih.gov/medlineplus/ency/presentations/100184_1.htm. Accessed on February 19, 2018. 
  5. National Library of Medicine. Medical Encyclopedia: Diastasis recti. Available at: http://www.nlm.nih.gov/medlineplus/ency/article/001602.htm. Accessed on February 19, 2018.
Document History

Status

Date

Action

Reviewed

03/22/2018

Medical Policy & Technology Assessment Committee (MPTAC) review. Updated header language from “Current Effective Date” to “Publish Date.” Updated Rationale and References sections.

Reviewed

08/03/2017

MPTAC review. Updated References section.

Reviewed

08/04/2016

MPTAC review. Updated formatting in Position Statement, Rationale and Reference sections. Removed ICD-9 codes from Coding section.

Revised

08/06/2015

MPTAC review. Revised formatting in criteria and clarified definition of ‘conventional treatment’. Updated Rationale, Coding, References, and Website sections.

Reviewed

08/14/2014

MPTAC review. Updated Rationale, Background/Overview, References, and Websites sections.

Reviewed

08/08/2013

MPTAC review. Updated Rationale, Background/Overview, References and Websites for Additional Information.

Reviewed

08/09/2012

MPTAC review. Updated Background/Overview. Removed Index section.

Revised

08/18/2011

MPTAC review. Significant weight loss is defined in the Position Statement as BMI less than or equal to 30 kg/m², or weight loss of at least 100 pounds, or has achieved a weight loss which is 40% or greater of the excess body weight that was present prior to the weight loss program or surgical intervention. Addition to Medically Necessary statement “well documented attempts at weight loss (medically supervised diet or bariatric surgery) have been unsuccessful”, addition to Medically Necessary statement that an individual who has had bariatric surgery has documented stable weight for at least 3 months. Regarding rashes and activities of daily living statements, the requirement for the information to be documented in office records was removed from the Position Statement. Updated Rationale and References.

Reviewed

02/17/2011

MPTAC review. Updated References.

Reviewed

02/25/2010

MPTAC review. References updated.

Reviewed

02/26/2009

MPTAC review. References updated.

Revised

02/21/2008

MPTAC review. Position Statement revised to reflect BMI rather than weight loss in pounds. Description, Rationale, Background, Definitions and References updated.

Reviewed

03/08/2007

MPTAC review. References updated.

 

01/01/2007

Updated Coding section with 01/01/2007 CPT/HCPCS changes; removed CPT 15831 deleted 12/31/2006.

Reviewed

03/23/2006

MPTAC review. References updated.

Revised

04/28/2005

MPTAC review. Revision based on Pre-merger Anthem and Pre-merger WellPoint Harmonization.

Pre-Merger Organizations

Last Review Date

Document Number

Title

Anthem, Inc.

 

04/28/2004

SURG.00048

Panniculectomy after Significant Weight Loss

WellPoint Health Networks, Inc.

12/02/2004

Clinical Guideline

Abdominoplasty

 

12/02/2004

Clinical Guideline

Diastasis Recti Repair