Clinical Policy: Panniculectomy Form

CENTENE Corporation

Clinical Policy: Panniculectomy Reference Number: CP.MP.109 Date of Last Revision: 08/25

Coding Implications Revision Log

See Important Reminder at the end of this policy for important regulatory and legal information.

Description Panniculectomy is the surgical removal of a panniculus or excess skin and adipose tissue that hangs down over the genital and/or thigh area causing difficulty in personal hygiene, walking, and other physical activity.

Policy/Criteria I. It is the policy of health plans affiliated with Centene Corporation that panniculectomy is

considered medically necessary when meeting all of the following indications:
A.  Panniculus hangs below the level of the pubis, documented by photographs;
B.  Medical records and photographs document at least one of the following chronic and
    persistent complications that remains refractory to appropriate therapy for at least
    three months. Appropriate medical therapy includes topical antifungals, topical and/or systemic
    corticosteroids, and/or local or systemic antibiotics, in addition to good hygiene practices;
    1.  Non-healing ulceration under panniculus;
    2.  Chronic maceration or necrosis of overhanging skin folds;
    3.  Recurrent or persistent skin infection under panniculus;
    4.  Intertriginous dermatitis or cellulitis or panniculitis;
C.  Panniculus limits physical activity or activities of daily living (ADLs);
D.  If panniculus is due to significant weight loss, one of the following:
    1.  Weight loss is not a result of bariatric surgery and there is evidence that a stable
        weight has been maintained for at least six months;
    2.  Weight loss is the result of bariatric surgery, weight has been stable for at least six
        months, and it has been at least 18 months since surgery.

Background Panniculectomy is a surgical procedure to remove an abdominal pannus or panniculus. A panniculus is formed secondary to obesity when there is a dense layer of fatty tissue growth on the abdomen that becomes large enough to hang down from the body. Panniculus size varies from grade 1, which reaches the mons pubis, to grade 5, which extends to or reaches past the knees.

Some areas of difficulty associated with a panniculus are personal hygiene, walking, and other physical activities. Sores and infections such as intertrigo, skin ulcers, and panniculitis can form in the folds of the panniculus, leading to painful inflammation of the tissue. This can further hinder physical activity and activities of daily life.

Panniculectomy is very similar to abdominoplasty, a surgical procedure that tightens the lax anterior abdominal wall muscles and trims excess adipose tissue and skin. Panniculectomy differs from abdominoplasty in the sense that abdominoplasty is usually performed as a cosmetic procedure to improve appearance but not function. Panniculectomy can be necessary for

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Clinical Policy Panniculectomy

restoring normal function or improving functional deficit as well as preventing sores and infections.

Coding Implications This clinical policy references Current Procedural Terminology (CPT®). CPT® is a registered trademark of the American Medical Association. All CPT codes and descriptions are copyrighted 2024, American Medical Association. All rights reserved. CPT codes and CPT descriptions are from the current manuals and those included herein are not intended to be all-inclusive and are included for informational purposes only. Codes referenced in this clinical policy are for informational purposes only. Inclusion or exclusion of any codes does not guarantee coverage. Providers should reference the most up-to-date sources of professional coding guidance prior to the submission of claims for reimbursement of covered services.

Reviews, Revisions, and Approvals

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Clinical Policy Panniculectomy

Important Reminder This clinical policy has been developed by appropriately experienced and licensed health care professionals based on a review and consideration of currently available generally accepted standards of medical practice; peer-reviewed medical literature; government agency/program approval status; evidence-based guidelines and positions of leading national health professional organizations; views of physicians practicing in relevant clinical areas affected by this clinical policy; and other available clinical information. The Health Plan makes no representations and accepts no liability with respect to the content of any external information used or relied upon in developing this clinical policy. This clinical policy is consistent with standards of medical practice current at the time that this clinical policy was approved. “Health Plan” means a health plan that has adopted this clinical policy and that is operated or administered, in whole or in part, by Centene Management Company, LLC, or any of such health plan’s affiliates, as applicable.

The purpose of this clinical policy is to provide a guide to medical necessity, which is a component of the guidelines used to assist in making coverage decisions and administering benefits. It does not constitute a contract or guarantee regarding payment or results. Coverage decisions and the administration of benefits are subject to all terms, conditions, exclusions and limitations of the coverage documents (e.g., evidence of coverage, certificate of coverage, policy, contract of insurance, etc.), as well as to state and federal requirements and applicable Health Plan-level administrative policies and procedures.

This clinical policy is effective as of the date determined by the Health Plan. The date of posting may not be the effective date of this clinical policy. This clinical policy may be subject to applicable legal and regulatory requirements relating to provider notification. If there is a discrepancy between the effective date of this clinical policy and any applicable legal or regulatory requirement, the requirements of law and regulation shall govern. The Health Plan retains the right to change, amend or withdraw this clinical policy, and additional clinical policies may be developed and adopted as needed, at any time.

This clinical policy does not constitute medical advice, medical treatment or medical care. It is not intended to dictate to providers how to practice medicine. Providers are expected to exercise

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Clinical Policy Panniculectomy

professional medical judgment in providing the most appropriate care and are solely responsible for the medical advice and treatment of members/enrollees. This clinical policy is not intended to recommend treatment for members/enrollees. Members/enrollees should consult with their treating physician in connection with diagnosis and treatment decisions.

Providers referred to in this clinical policy are independent contractors who exercise independent judgment and over whom the Health Plan has no control or right of control. Providers are not agents or employees of the Health Plan.

This clinical policy is the property of the Health Plan. Unauthorized copying, use, and distribution of this clinical policy or any information contained herein are strictly prohibited. Providers, members/enrollees and their representatives are bound to the terms and conditions expressed herein through the terms of their contracts. Where no such contract exists, providers, members/enrollees and their representatives agree to be bound by such terms and conditions by providing services to members/enrollees and/or submitting claims for payment for such services.

Note: For Medicaid members/enrollees, when state Medicaid coverage provisions conflict with the coverage provisions in this clinical policy, state Medicaid coverage provisions take precedence. Please refer to the state Medicaid manual for any coverage provisions pertaining to this clinical policy.

Note: For Medicare members/enrollees, to ensure consistency with the Medicare National Coverage Determinations (NCD) and Local Coverage Determinations (LCD), all applicable NCDs, LCDs, and Medicare Coverage Articles should be reviewed prior to applying the criteria set forth in this clinical policy. Refer to the CMS website at http://www.cms.gov for additional information.