Coverage Policy

The following Coverage Policy applies to health benefit plans administered by Cigna Companies. Certain Cigna Companies and/or lines of business only provide utilization review services to clients and do not make coverage determinations. References to standard benefit plan language and coverage determinations do not apply to those clients.

Coverage Policies are intended to provide guidance in interpreting certain standard benefit plans administered by Cigna Companies. Please note, the terms of a customer's particular benefit plan document [Group Service Agreement, Evidence of Coverage, Certificate of Coverage, Summary Plan Description (SPD) or similar plan document] may differ significantly from the standard benefit plans upon which these Coverage Policies are based. For example, a customer's benefit plan document may contain a specific exclusion related to a topic addressed in a Coverage Policy. In the event of a conflict, a customer's benefit plan document always supersedes the information in the Coverage Policies. In the absence of a controlling federal or state coverage mandate, benefits are ultimately determined by the terms of the applicable benefit plan document.

Coverage determinations in each specific instance require consideration of 1) the terms of the applicable benefit plan document in effect on the date of service; 2) any applicable laws/regulations; 3) any relevant collateral source materials including Coverage Policies and; 4) the specific facts of the particular situation. Each coverage request should be reviewed on its own merits. Medical directors are expected to exercise clinical judgment and have discretion in making individual coverage determinations.

Coverage Policies relate exclusively to the administration of health benefit plans. Coverage Policies are not recommendations for treatment and should never be used as treatment guidelines.

In certain markets, delegated vendor guidelines may be used to support medical necessity and other coverage determinations.

This Coverage Policy addresses surgical procedures performed to re-shape or remove hanging fat and skin from the abdominal area.

Coverage Policy

Coverage for panniculectomy and abdominoplasty varies across plans. Refer to the customer's benefit plan document for coverage details.

Panniculectomy is considered medically necessary when ALL of the following conditions are met as demonstrated on preoperative photographs:

• The pannus hangs at or below the level of the symphysis pubis.
• The pannus is causing persistent intertriginous dermatitis, cellulitis, or skin ulceration, which is refractory to at least three (3) months of medical management, including all applicable treatments. In addition to good hygiene practices, treatment should include topical antifungals, topical and/or systemic corticosteroids, and/or local or systemic antibiotics.
• There is presence of a functional deficit due to a severe physical deformity or disfigurement resulting from the pannus. The surgery is expected to restore or improve the functional deficit.
• The pannus is interfering with activities of daily living.

Note: If the procedure is being performed following significant weight loss, in addition to meeting the criteria noted above, there should be evidence that the individual has maintained a stable weight for at least six months. If the weight loss is the result of bariatric surgery, panniculectomy should not be performed until at least 18 months after bariatric surgery and only when weight has been stable for at least the most recent six months.

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Panniculectomy is considered not medically necessary for ANY other indication, including but not limited to the following:

• when performed in conjunction with abdominal or gynecological procedures (e.g., abdominal hernia repair, hysterectomy, obesity surgery) unless criteria for panniculectomy are met separately
• treatment of neck or back pain
• improving appearance (i.e., cosmesis)
• treating psychological symptomatology or psychosocial complaints

Abdominoplasty is considered cosmetic in nature and not medically necessary for ANY indication, including but not limited to the following:

• when performed in conjunction with abdominal or gynecological procedures (e.g., abdominal hernia repair, hysterectomy, obesity surgery)
• repairing abdominal wall laxity
• treatment of neck or back pain
• treating psychological symptomatology or psychosocial complaints

Surgical procedures to correct diastasis recti are considered cosmetic in nature and not medically necessary for ANY indication.

Suction-assisted lipectomy used in conjunction with a panniculectomy is considered integral to the primary procedure and will not be separately reimbursed.

General Background

Overweight and obesity are defined as abnormal or excessive fat accumulation that may impair health. Body mass index (BMI) is commonly used to classify overweight and obesity in adults. According to the World Health Organization (WHO) overweight is defined as a BMI greater than or equal to 25 and obesity is a BMI greater than or equal to 30 (WHO, 2020). Centers for Disease Control and Prevention (CDC) further divides obesity into categories (CDC 2022):

• Class 1: BMI of 30 to < 35
• Class 2: BMI of 35 to < 40
• Class 3: BMI of 40 or higher. Class 3 obesity is sometimes categorized as “severe” obesity.

The CDC National Center for Health Statistics (NCHS) data brief reports the prevalence of obesity was similar between men and women. However, severe obesity was highest in women and adults aged 40–59. Obesity and severe obesity was highest in non-Hispanic black adults compared with other race and Hispanic-origin groups. Obesity was lowest among non-Hispanic Asian adults compared to non-Hispanic white, Hispanic and non- Hispanic black adults. Non-Hispanic black women had a higher prevalence of obesity than non-Hispanic black men (Hales, et al., 2020).

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Obesity and weight gain can cause an apron of skin and fat that hangs down from the abdomen which is called an abdominal pannus. The excess skin and fat can sometimes cover the anterior thighs, hips, and knees. A large pannus can interfere with activities of daily living and cause skin infections and rashes (Sachs, et al., 2020).

Panniculectomy: A panniculectomy is the removal of hanging excess skin/fat in a transverse or vertical wedge but does not include muscle plication, neoumbilicoplasty or flap elevation. Deformities associated with massive weight gain or loss vary depending on the patients’ body type and their fat deposition pattern. These deformities can lead to patient dissatisfaction with appearance; inability to exercise; impaired ambulation; chronic back; neck, and shoulder pain; difficulty with hygiene; uncontrolled intertrigo; infections; and skin necrosis. The severity of abdominal deformities is graded as follows (American Society of Plastic Surgeons [ASPS], 2017):

• Grade 1: panniculus covers hairline and mons pubis but not the genitals
• Grade 2: panniculus covers genitals and upper thigh crease
• Grade 3: panniculus covers upper thigh
• Grade 4: panniculus covers mid-thigh
• Grade 5: panniculus covers knees and below

Treatment of this redundant skin and fat is often performed solely for cosmesis, to improve the appearance of the abdominal area.

The presence of a massive overhanging apron of fat and skin, however, may result in chronic and persistent local skin conditions in the abdominal folds. These conditions may include intertrigo, intertriginous dermatitis, cellulitis, ulcerations or tissue necrosis, or they may lead to painful inflammation of the subcutaneous adipose tissue (i.e., panniculitis). When panniculitis is severe, it may interfere with activities of daily living, such as personal hygiene and ambulation.

In addition to excellent personal hygiene practices, treatment of these skin conditions generally involves topical or systemic corticosteroids, topical antifungals, and topical or systemic antibiotics. In general, a panniculectomy may be indicated when the panniculus hangs below the level of the symphysis pubis with a chronic and persistent skin condition (e.g., intertrigo, cellulitis, or tissue necrosis) that has not responded to conventional treatment and the panniculus interferes with activities of daily living.

Concurrent abdominal and pelvic surgical procedures (e.g., hernia repair, hysterectomy, obesity surgery) may also be performed in the same operative setting as panniculectomy or abdominoplasty. Based on retrospective studies, older patients who smoke and have a higher BMI are at increased risk for post-operative complications.

There is a discrepancy between patients who complain of excess skin after bariatric surgery and those who have a panniculectomy. Possible causes of this are the cost of the panniculectomy (Caldwell, et al., 2021; Kuruoglu, et al., 2021; Derickson, et al., 2018; Altieri, et al., 2017).

A retrospective study by Rhemtulla et al. (2019), evaluated the disparity in patients receiving panniculectomies and assessed if the disparity persists once patients are integrated into the healthcare system through bariatric surgery. All patients who received bariatric surgery (n=2528), standalone panniculectomies (n=1333) and panniculectomies after bariatric surgery (n=48). Forty-three percent of bariatric surgery patients were African American compared to 25% of all standalone panniculectomy patients and 52% of panniculectomy after bariatric surgery patients. The racial disparity was not observed when patients received a panniculectomy after bariatric surgery (p<0.001). Women made up the majority of patients in the study. The study concluded that the racial disparity observed in patients receiving panniculectomies was not present when patients were integrated into the healthcare system through bariatric surgery.

Additional studies should include an assessment of insurance coverage, income, provider knowledge and patient health literacy.

Literature Review

Panniculectomy: A Hayes Medical Technology Directory report evaluated the evidence (n=11 studies) on the efficacy and safety of a panniculectomy. The review included six poor-quality retrospective cohort studies and five very-poor-quality retrospective uncontrolled studies. No randomized controlled trials, prospective studies or other well-designed studies were identified that met the study inclusion criteria. Study sample sizes ranged from 50–577 patients. Outcomes measured were postoperative complications (e.g., seroma, wound infection, cellulitis, hematoma, dehiscence, deep vein thrombosis, pulmonary embolism), postoperative outcomes (panniculus weight postexcision, need for blood transfusion, hospital length of stay, hospital readmission, death), and patient satisfaction. Reported outcomes focused almost entirely on postoperative wound complications. There were no objective measures of efficacy, such as improvement in symptoms or panniculus severity after surgery.

The evidence base almost entirely reflects postoperative complications and lacks studies that evaluate objective efficacy outcomes. However, there are consistent Medical Coverage Policy: 0027 findings that panniculectomy is generally a safe and tolerable procedure in patients who have lost weight after undergoing bariatric surgery or when performed at the time of bariatric surgery in obese patients. The annual review in 2020 did not change the conclusions of the original review (Hayes, 2016).

Abdominoplasty:

Abdominoplasty, also referred to in lay terms as a "tummy tuck," is performed to treat laxity of the abdominal wall musculature, excess skin, striae, or diastasis of the rectus muscles. The surgical procedure tightens lax anterior abdominal wall muscles and removes excess abdominal skin and fat. This recontouring of the abdominal wall area is generally performed solely for cosmetic purposes in order to improve the appearance of the abdominal area and is not associated with functional improvement.

The standard abdominoplasty involves plication of the anterior rectus sheath for muscle diastasis (i.e., repair of diastasis recti) and removal of excess fat and skin. Traditional abdominoplasty can be performed as an open procedure or endoscopically. Abdominoplasty completed by endoscopic guidance is usually reserved for those patients who seek less extensive contouring of the abdominal wall. Mini-abdominoplasty, with or without liposuction, is a partial abdominoplasty involving the incision of the lower abdomen only.

Literature Review Abdominoplasty:

There has been no correlation established between the presence of abdominal wall laxity or redundant pannus and the development of neck or back pain. There is insufficient evidence in the published, peer-reviewed scientific literature to support the use of abdominoplasty and/or panniculectomy to treat neck or back pain, including pain in the cervical, thoracic, lumbar or lumbosacral regions. Abdominoplasty or panniculectomy is considered not medically necessary when performed for the sole purpose of treating neck or back pain.

Abdominal surgeries such as hernia repair (i.e., incisional/ventral, epigastric or umbilical) or obesity surgery may be performed alone or in combination with abdominoplasty and panniculectomy. In addition, some surgeons perform these procedures at the same time as gynecological or pelvic procedures, such as hysterectomy. Although it has been proposed that performing abdominoplasty or panniculectomy in the same operative session as abdominal or gynecological surgeries may facilitate surgical access or promote postoperative wound healing and minimize the potential for wound complications, such as dehiscence or necrosis, there is insufficient evidence in the published, peer-reviewed scientific literature to support such assertions.

Performing an abdominoplasty at the same operative session as abdominal operations (e.g., hernia repair, gastric bypass) or gynecological procedures is not essential for the successful clinical outcome of the abdominal or gynecological surgical procedure. In the absence of chronic and persistent skin conditions or interference with activities of daily living, abdominoplasty and panniculectomy are considered not medically necessary when performed in conjunction with abdominal or pelvic/gynecological surgeries to facilitate surgical access, to promote postoperative wound healing, or to minimize wound complications.

Diastasis Recti:

Diastasis recti is a condition that involves the separation of the two sides of the rectus abdominis muscles in the midline at the linea alba. Other than its untoward cosmetic appearance, diastasis recti does not lead to any complications that require intervention.

Diastasis recti has no clinical significance, does not require treatment and is not considered a true hernia (Jeyarajah and Harford, 2010). Conservative management with weight loss and exercise are advised as a first-line treatment. Surgical methods to repair diastasis rectus differ by approach (open versus laparoscopic), numbers of layers of sutures, the position of suture placement, suture material used, and whether or not mesh is used. Plication of the rectus sheath is often performed in conjunction with abdominoplasty; however, plication alone is an option for those without excessive skin laxity (Nahabedian and Brooks, 2022). Surgical procedures to correct diastasis recti are not medically indicated.

Suction-Assisted Lipectomy:

Suction-assisted lipectomy of the abdominal area is a procedure in which excess fat deposits are removed from the trunk using a liposuction cannula with the goal of recontouring the body, thereby improving appearance. This procedure may be performed alone or as one component of the overall abdominoplasty or panniculectomy procedure. Suction-assisted lipectomy is considered cosmetic in nature when performed alone and not as part of a medically necessary panniculectomy. When the procedure is performed as part of a medically necessary panniculectomy, suction-assisted lipectomy of the trunk is considered incidental to the primary procedure.

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Professional Societies/Organizations

American Society of Plastic Surgeons (ASPS): The ASPS coverage criteria for the surgical treatment of skin redundancy for obese and massive weight loss patients, stated that abdominoplasty and circumferential lipectomy typically would be considered cosmetic procedures. However, when a panniculectomy is preformed to eliminate a large hanging abdominal panniculus to reduce associated symptoms, cellulitis, intertrigo, shoulder pain, neck pain, back pain, thoracic spine pain, lumbago, and panniculitis, it would be considered reconstructive (ASPS, 2017). The ASPS recommended coverage criteria for abdominoplasty stated that abdominoplasties are typically performed for purely cosmetic indications such as unacceptable appearance due to fat maldistribution or contour deformities. When an abdominoplasty is performed solely to enhance a patient's appearance in the absence of any signs or symptoms of functional abnormalities, the procedure should be considered cosmetic. Additionally, if a panniculectomy is combined with plication of the rectus abdominis muscle, it should be considered purely cosmetic (ASPS, 2006, reaffirmed 2018).

Use Outside of the US

No relevant information.