Description

A panniculectomy is a surgical procedure designed to remove a panniculus or pannus, (excess apron of redundant skin and fat) from the abdomen and generally does not include tightening of the abdominal muscles.

Abdominoplasty (also called a tummy tuck) is a surgical procedure involving the removal of excess skin and fat from the middle and lower abdomen with tightening or repair of weak or separated abdominal muscles. (Refer to Coverage Limitations section)

Panniculectomy, Abdominoplasty, Abdominal Contouring

Effective Date: 11/02/2023

Revision Date: 11/02/2023

Review Date: 11/02/2023

Policy Number: HUM-0360-017

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Abdominal contouring via liposuction (also called suction assisted lipectomy) is a surgical procedure designed to remove fat under the abdominal skin to improve appearance. (Refer to Coverage Limitations section)

Rectus abdominis diastasis (RAD) appears as a bulge in the abdomen as a result of lengthwise separation of the rectus abdominus muscles. This may be confused with a hernia, however, it is not a true hernia, as there is no underlying fascial defect. In RAD, the underlying fascia (connective tissue) is intact and therefore, there is no herniation of intra-abdominal contents, unlike a true hernia (which involves a hole in the abdominal wall through which internal organs may protrude). RAD does not represent a clinically significant medical condition and its repair is generally considered elective and cosmetic. RAD may also be called diastasis recti, rectus diastasis. (Refer to Coverage Limitations section)

For information regarding brachioplasty (upper arm lift), skin removal and thighplasty (thigh/buttock lift), please refer to Cosmetic and Reconstructive Surgery Medical Coverage Policy.

Coverage Determination

When panniculectomy is requested in conjunction with any other procedures, the criteria for each procedure must be met.

Humana members may be eligible under the Plan for panniculectomy for the following indications:

• Documentation of a panniculus at grade 2 or above; AND
• Medical complications due to excess tissue and skin folds (eg, candidiasis, intertrigo or tissue necrosis) not relieved or controlled by at least 12 consecutive weeks of prescribed oral and/or topical dermatological therapy (eg, antibiotics, antifungals, corticosteroids) or other prescribed treatment if medically appropriate and not contraindicated; AND
• IF panniculectomy is performed following significant weight loss:
  • ALL criteria above must be met; AND
  • Member certificate must specifically include language allowing benefits for surgical procedures for the removal of excess skin and/or fat in conjunction with or resulting from weight loss or weight loss surgery; AND
  • Stable body weight (no loss or gain greater than 3% of weight) has been maintained for at least six months

Coverage Limitations

Humana members may NOT be eligible under the Plan for panniculectomy for cosmetic purposes or for any indications other than those listed above. All other indications are considered not medically necessary as defined in the member’s individual certificate.

Please refer to the member’s individual certificate for the specific definition.

Humana members may NOT be eligible under the Plan for the following procedures for any indications:

• Abdominal liposuction (suction assisted lipectomy); OR
• Abdominoplasty; OR
• Rectus abdominis diastasis (RAD) repair

These are considered cosmetic and are performed to improve or change appearance or self-esteem. Please refer to the member’s individual certificate for the specific definition.

Humana members may NOT be eligible under the Plan for the surgical removal of excess skin and/or fat in conjunction with, or resulting from, weight loss or weight loss surgery, as it may be excluded by certificate. In the absence of certificate language specifically allowing the benefit, this is considered not medically necessary as defined in the member’s individual certificate.

Background

Additional information about candidiasis, intertrigo, obesity, or rectus abdominis diastasis may be found from the following websites:

• American Society of Plastic Surgeons
• Centers for Disease Control and Prevention
• National Library of Medicine

Medical Alternatives

Physician consultation is advised to make an informed decision based on an individual’s health needs.

Any CPT, HCPCS or ICD codes listed on this medical coverage policy are for informational purposes only. Do not rely on the accuracy and inclusion of specific codes. Inclusion of a code does not guarantee coverage and or reimbursement for a service or procedure.