Criteria for documenting medical necessity of panniculectomy
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A panniculectomy is the surgical removal of fat and excess skin hanging from the lower part of the abdomen, called a panniculus or a pannus. This “apron” of excess fat and skin usually occurs in people who have lost a lot of weight. It can cause rashes, infections, and chronic pain, which is why it sometimes becomes necessary to have it removed through surgery.
What both procedures do. A tummy tuck — called an abdominoplasty — also removes excess skin and fat from the abdomen. However, instead of just removing the “apron” hanging from the lower part of the abdomen, a tummy tuck may involve removing fat and skin from the upper abdomen as well. Repair and tightening of the abdominal muscles is often included in a tummy tuck (but not in a panniculectomy) and liposuction may also be done on the sides of the belly for additional contouring.
Insurance coverage of a panniculectomy vs. a tummy tuck. A panniculectomy may be covered by insurance if it is found to be medically necessary*, such as when the panniculus causes intertrigo. A tummy tuck, on the other hand, is mostly done for cosmetic reasons — to improve appearance — and is rarely covered by insurance.
* See the reference list at the end of the article for links to the panniculectomy requirements / medical necessity criteria of Aetna, Anthem Blue Cross, Blue Cross Blue Shield of North Carolina, Cigna, Tricare, UnitedHealthcare (UHC), WellCare, and other health plans.
When is panniculectomy medically necessary?
For panniculectomy to be considered medically necessary, the patient must meet the following criteria:
In rare circumstances, panniculectomy may be considered a medically necessary adjunct to another medically necessary surgery, for example:
Some state mandates may require health plans to cover panniculectomy in the context of HIV-associated lipodystrophy syndrome.
Panniculectomy is considered experimental, investigational, and/or not medically necessary for:
Medicare panniculectomy guidelines
Medicare may consider panniculectomy medically necessary when the panniculus hangs below the level of the pubis and the procedure is being done to address complications created by the hanging skin fold, such as:
Medicare may not cover panniculectomy for the following conditions because it is considered experimental, investigational, and/or not medically necessary for these indications:
If panniculectomy is done together with other abdominal or gynecological procedures, the medical necessity criteria for panniculectomy must be met separately, otherwise it will not be covered.
Medicaid generally covers panniculectomy when it is medically necessary. Although specific medical necessity criteria may vary from state to state, it is generally required that: the panniculus hangs at or below the level of the symphysis pubis; it causes a chronic and persistent skin condition that is refractory to at least three to six months of medical treatment, and/or it interferes with activities of daily living; and the patient has maintained a stable weight/BMI over the past six months.
Abdominoplasty, or tummy tuck, is considered a cosmetic procedure by most health plans and therefore not medically necessary.
It is NOT considered medically necessary for the treatment of back or neck pain.
The following are also considered cosmetic and not medically necessary:
Repair of diastasis recti is considered cosmetic — it is not considered a true hernia and has no clinical significance — and therefore not medically necessary.
However, repair of a true incisional or ventral hernia would be considered medically necessary.
Generally, removal of excess skin — whether in the arms, buttocks, thighs, or as part of a panniculus — would be considered medically necessary when the excess skin is causing significant physical functional impairment or symptoms that persist despite optimal medical management but are reasonably expected to improve once the excess skin is surgically removed.
Otherwise, procedures to remove redundant or excess skin in the arms, torso, buttocks, hips, thighs, or legs — such as the procedures listed below — are considered cosmetic and not medically necessary: