Anthem Blue Cross Connecticut CG-SURG-99 Panniculectomy and Abdominoplasty Form

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 functional impairment AND the procedure can be reasonably expected to improve the 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.

Clinical Indications

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 when used for the removal of excess abdominal fat.
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.