Prior authorization request form Form

Abdominoplasty/Panniculectomy

Last Review Date: August 8, 2025   
Number: MG.MM.SU.09iC2

Medical Guideline Disclaimer Property of EmblemHealth. All rights reserved. The treating physician or primary care provider must submit to EmblemHealth the clinical evidence that the patient meets the criteria for the treatment or surgical procedure. Without this documentation and information, EmblemHealth will not be able to properly review the request for prior authorization. The clinical review criteria expressed below reflects how EmblemHealth determines whether certain services or supplies are medically necessary. EmblemHealth established the clinical review criteria based upon a review of currently available clinical information (including clinical outcome studies in the peer reviewed published medical literature, regulatory status of the technology, evidence-based guidelines of public health and health research agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas, and other relevant factors). EmblemHealth expressly reserves the right to revise these conclusions as clinical information changes and welcomes further relevant information. Each benefit program defines which services are covered. The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered and/or paid for by EmblemHealth, as some programs exclude coverage for services or supplies that EmblemHealth considers medically necessary. If there is a discrepancy between this guideline and a member's benefits program, the benefits program will govern. In addition, coverage may be mandated by applicable legal requirements of a state, the Federal Government or the Centers for Medicare & Medicaid Services (CMS) for Medicare and Medicaid members. All coding and web site links are accurate at time of publication. EmblemHealth Services Company LLC, (“EmblemHealth”) has adopted the herein policy in providing management, administrative and other services to EmblemHealth Plan, Inc., EmblemHealth Insurance Company, EmblemHealth Services Company, LLC and Health Insurance Plan of Greater New York (HIP) related to health benefit plans offered by these entities. All of the aforementioned entities are affiliated companies under common control of EmblemHealth Inc.

Related Medical Guideline Cosmetic Surgery and Reconstructive Procedures
Requests will be considered using Milliman Clinical Care Guidelines (MCGs). Guidelines are developed using publications that have been assessed in terms of quality, utility, and relevance. Preference is given to publications that:  Are designed with rigorous scientific methodology  Are published in higher-quality journals (e.g., journals that are read and cited most often within their field)  Address an aspect of specific importance to the guideline in question (admission criteria, length of stay)  Represent an update or contain new data or information not reflected in the current guideline MCG Clinical Criteria  A-0497 — Abdominoplasty  A-0498 — Panniculectomy  WS-GRG — Wound and Skin Management GRG Note: In the case that more than one procedure is to be performed, coverage will only be applicable to the reconstructive procedure; the cost of the cosmetic procedure (i.e., abdominoplasty in association with panniculectomy) will be the responsibility of the member (as per group contract, individual contract or policy). Additionally, photographic evidence must accompany written documentation substantiating medical necessity as follows:  Panniculus hangs below level of pubis (below the distal end of the symphysis pubis), documented by high-quality color frontal-view and side-view photographs  Documentation of high-quality color frontal-view and side-view photographs with pannus lifted to document presence of intertrigo (as applicable)

Revision History

Aug. 11, 2023 Added photo documentation criteria Aug. 13, 2021 Updated policy with MCG specific guidelines and retained note pertaining to:  Differentiation between cosmetic and reconstructive procedures when multiple procedures are performed  Photo documentation
Jul. 12, 2019 Reinstated policy Aug. 17, 2018 Retired for MCG Mar. 11, 2016 Added that documentation should delineate reason for interference of activities of daily living