Abdominal Panniculectomy and Excision of Excessive Skin and Subcutaneous Tissue Form

1

Abdominal Panniculectomy and Excision of Excessive Skin and Subcutaneous Tissue - Medical Policy
Updated Revision Effective: March 1, 2024 Policy Number:

UM238POL

Approval Date: 12/20/2023

Line(s) of Business:

FF
SF
Medicare
MedSupp-G
MedSupp-I
Medicaid

Description

Panniculectomy is the removal of an apron of hanging fat and skin, which may be performed with or without an abdominoplasty or "tummy tuck," a surgical procedure that tightens the abdominal wall muscles, removes excess skin and fat, and provides contouring to enhance the waistline. Lipectomy (removal of excess fat deposits using a liposuction cannula) may be performed as a component of panniculectomy but, when performed alone, is considered cosmetic and not medically necessary

Line of Business Commercial:
 For excision of excessive skin and subcutaneous tissue, except for abdominal panniculectomy, refer to criteria under Policy section in this medical policy.  For abdominal panniculectomy Health New England (HNE) has adopted InterQual* criteria for Commercial line of business: Panniculectomy, Abdominal

*To obtain InterQual® SmartSheets™: If you are a registered Health New England provider click here: https://www.hnedirect.com/login/ to access the Provider website. If you do not have access to the portal call (413) 787-4004 to obtain a copy.

Medicaid – BeHealthy:
 For excision of excessive skin and subcutaneous tissue, except for abdominal panniculectomy, Health New England follows MassHealth Guidelines for Medical Necessity Determination for Excision of Excessive Skin and Subcutaneous Tissue. https://www.mass.gov/doc/guidelines-for-medical-necessity- determination-for-excision-of-excessive-skin-and-subcutaneous-tissue-0/download
 For abdominal panniculectomy , Health New England follows MassHealth Guidelines for Medical Necessity Determination for Panniculectomy. https://www.mass.gov/doc/panniculectomy/download

Medicare:

2

 For excision of excessive skin and subcutaneous tissue, except for abdominal panniculectomy, refer to criteria under Policy section in this medical policy Medicare does not have a National Coverage Determination (NCD) or a Local Coverage Determination (LCD) for excision of excessive skin  For abdominal panniculectomy Health New England follows Local Coverage Determination (LCD) Cosmetic and Reconstructive Surgery (L39051), for Abdominal Panniculectomy for Medicare line of business. https://www.cms.gov/medicare-coverage-database/search.aspx

Policy

I. Health New England (HNE) has adopted InterQual criteria for Commercial line of business: CP: Procedures Panniculectomy, Abdominal, for commercial line of business.

II. HNE considers Excision of excessive skin and subcutaneous tissue (e.g., from thighs, hips, buttocks, and/or arms) MEDICALLY NECESSARY for commercial line of business when documentation confirms ALL of the following:

a. Weight loss has resulted in significant excess/redundant skin or skin folds; AND b. Redundant skin and/or skin folds directly cause ALL of the following: c. A physical functional impairment that interferes with activities of daily living including physical exercise; AND d. Persistent symptomatic intertriginous ulcerations or macerations that have been refractory to good personal hygiene and physician-supervised local treatment over a period of several months; AND e. Documentation must include a detailed description of all physician-supervised skin treatment; AND f. Recurrent skin infections (at least 2 episodes within 12 months) that require systemic antibiotics and are directly related to the redundant skin. Documentation must confirm episodes are refractory to at least a full course of antibiotic treatment.

III. Abdominal Panniculectomy and Excision of excessive skin and subcutaneous tissue for conditions that do not meet above criteria are considered EXPERIMENTAL and INVESTIGATIONAL.

IV. For Medicare: If the criteria above is not met, it may be considered cosmetic. The CMS Benefit Policy Manual, Chapter 16, §120 states that: Cosmetic surgery or expenses incurred in connection with such surgery are not covered. Cosmetic surgery includes any surgical procedure directed at improving appearance, except when required for the prompt (i.e., as soon as medically feasible) repair of accidental injury or for the improvement of the functioning of a malformed body member. https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/bp102c16.pdf

Coding Guidance

3

Code
Description
PA 15830 Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy Yes 15832 Excision, excessive skin and subcutaneous tissue (includes lipectomy); thigh Yes 15833 Excision, excessive skin and subcutaneous tissue (includes lipectomy); leg Yes 15834 Excision, excessive skin and subcutaneous tissue (includes lipectomy); hip Yes 15835 Excision, excessive skin and subcutaneous tissue (includes lipectomy); buttock Yes 15836 Excision, excessive skin and subcutaneous tissue (includes lipectomy); arm Yes 15837 Excision, excessive skin and subcutaneous tissue (includes lipectomy); forearm or hand Yes 15838 Excision, excessive skin and subcutaneous tissue (includes lipectomy); submental fat pad Yes 15839 Excision, excessive skin and subcutaneous tissue (includes lipectomy); other area Yes 15847 Excision, excessive skin and subcutaneous tissue (includes lipectomy), abdomen (eg, abdominoplasty) (includes umbilical transposition and fascial plication) (List separately in addition to code for primary procedure) Not covered

CPT® Copyright 2023 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Note: CPT/HCPCS codes are included for informational purposes and may not be all inclusive. Inclusion or exclusion of a CPT/HCPCS code(s) does not signify or imply that the service described by the code is a covered or non-covered health service. Benefit coverage for health services is determined by the member’s specific benefit plan document and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee of payment. Other policies and coverage determination guidelines may apply.

Policy Implementation

Approved by the Medical and Pharmacy Policy Committee

Kate McIntosh MD MBA

Chief Medical Officer

Saad Usmani MD MBA

Medical Director

Date Update 12/2005 Initial policy date 11/2023  Title changed to Abdominal Panniculectomy and Excision of excessive skin and subcutaneous tissue.  Commercial criteria changed to InterQual for Panniculectomy.  LCD added for Medicare line of business for Panniculectomy.  MassHealth guidelines added.

4

Medical Criteria Disclaimer

Property of Health New England. All rights reserved. The treating physician or primary care provider must submit to Health New England the clinical evidence that the patient meets the criteria for the treatment, testing or surgical procedure. Without this documentation and information, Health New England will not be able to properly review the request for prior authorization. The clinical review criteria reflect how Health New England determines whether certain services or supplies are medically necessary. Health New England 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).
Health New England 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 Health New England, as some programs exclude coverage for services or supplies that Health New England 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. Health New England has adopted the herein policy in providing management, administrative and other services to its Health Plan.