Sunflower Health Plan Panniculectomy (PDF) Form

Panniculectomy is the surgical removal of a panniculus or excess skin and adipose tissue that hangs down over the genital and/or thigh area causing difficulty in personal hygiene, walking, and other physical activity. Policy/Criteria I. It is the policy of health plans affiliated with Centene Corporation that panniculectomy is considered medically necessary when meeting all of the following indications: A. Panniculus hangs below the level of the pubis, documented by photographs; B. Medical records and photographs document at least one of the following chronic and persistent complications that remains refractory to appropriate therapy for at least three months. Appropriate medical therapy includes topical antifungals, topical and/or systemic corticosteroids, and/or local or systemic antibiotics, in addition to good hygiene practices; 1. Non-healing ulceration under panniculus; 2. Chronic maceration or necrosis of overhanging skin folds; 3. Recurrent or persistent skin infection under panniculus; 4. Intertriginous dermatitis or cellulitis or panniculitis; C. Panniculectomy is expected to restore normal function or improve functional deficit; D. If panniculus is due to significant weight loss, one of the following: 1. Weight loss is not a result of bariatric surgery and there is evidence that a stable weight has been maintained for at least six months; 2. Weight loss is the result of bariatric surgery, weight has been stable for at least six months, and it has been at least 18 months since surgery. Background Panniculectomy is a surgical procedure to remove an abdominal pannus or panniculus. A panniculus is formed secondary to obesity when there is a dense layer of fatty tissue growth on the abdomen that becomes large enough to hang down from the body. Panniculus size varies from grade 1, which reaches the mons pubis, to grade 5, which extends to or reaches past the knees. Some areas of difficulty associated with a panniculus are personal hygiene, walking, and other physical activities. Sores and infections such as intertrigo, skin ulcers, and panniculitis can form in the folds of the panniculus, leading to painful inflammation of the tissue. This can further hinder physical activity and activities of daily life. Panniculectomy is very similar to abdominoplasty, a surgical procedure that tightens the lax anterior abdominal wall muscles and trims excess adipose tissue and skin. Panniculectomy differs from abdominoplasty in the sense that abdominoplasty is usually performed as a cosmetic procedure to improve appearance but not function. Panniculectomy can be necessary for Page 1 of 4 CLINICAL POLICY Panniculectomy restoring normal function or improving functional deficit as well as preventing sores and infections. Coding Implications This clinical policy references Current Procedural Terminology (CPT®). CPT® is a registered trademark of the American Medical Association. All CPT codes and descriptions are copyrighted 2022, American Medical Association. All rights reserved. CPT codes and CPT descriptions are from the current manuals and those included herein are not intended to be all-inclusive and are included for informational purposes only. Codes referenced in this clinical policy are for informational purposes only. Inclusion or exclusion of any codes does not guarantee coverage. Providers should reference the most up-to-date sources of professional coding guidance prior to the submission of claims for reimbursement of covered services. CPT® Codes 15830 Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy Reviews, Revisions, and Approvals Criteria separated from CP.MP.31 Cosmetic and Reconstructive Surgery References reviewed and updated. ICD -10 codes added. References reviewed and updated. Specialist reviewed. Annual review. Replaced all instances of member with member/enrollee. Expanded criteria for complications related to pannus to include non- healing ulceration under panniculus, chronic maceration or necrosis of overhanging skin folds, recurrent or persistent skin infection under panniculus, intertriginous dermatitis or cellulitis or panniculitis. Added the following ICD 10 codes: L03.319, L03.818, L98.499. Separated “D.” into separate criteria points, D. and E, adding that bariatric surgery weight loss must be stable for 6 months. Annual review. Changed “review date” in the header to “date of last revision” and “date” in the revision log header to “revision date.” References reviewed, updated, and reformatted. Minor verbiage changes with no clinical significance. Reviewed by specialist. Annual review. Removed ICD-10 codes. References reviewed and updated. Annual Review. Combined criteria I.D. and E. into criteria I.D.1. and 2. Removed CPT code 00802 from policy. References reviewed and updated. Reviewed by external specialist. Revision Date 04/16 03/19 02/20 Approval Date 04/16 03/19 03/20 02/21 03/21 11/21 11/21 10/22 10/22 10/23 10/23