Panniculectomy, Tummy Tuck, and Excess Skin Removal - Medical Necessity Criteria
Criteria for documenting medical necessity of panniculectomy
Contents:
- What is a panniculectomy?
- What is the difference between a panniculectomy and a tummy tuck?
- Medical necessity criteria for panniculectomy
- Is panniculectomy covered by Medicare?
- Is panniculectomy covered by Medicaid?
- When is abdominoplasty medically necessary?
- When is repair of diastasis recti medically necessary?
- When is excess skin removal medically necessary?
- Health plan criteria for panniculectomy and other references
What is a panniculectomy?
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 is the difference between a panniculectomy and a tummy tuck?
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.
Medical necessity criteria for panniculectomy
When is panniculectomy medically necessary?
For panniculectomy to be considered medically necessary, the patient must meet the following criteria:
- The panniculus (or pannus) hangs below the level of the pubis.
- The panniculus is causing either of these conditions, which must be documented in the patient’s medical record:
- Persistent rashes/dermatitis, cellulitis, infections, or non-healing ulcers that have not resolved despite at least three months of all applicable conservative treatments such as good hygiene, antibiotics, antifungals, corticosteroids, and/or dressing changes; or
- Functional impairment — such as difficulties with ambulation or activities of daily living — which is expected to improve if the panniculus is removed surgically.
- The patient must have maintained a stable weight for at least six months (some health plans require only three months). If the patient plans to lose [more] weight, he/she is typically advised to do this first before getting the panniculectomy.
In rare circumstances, panniculectomy may be considered a medically necessary adjunct to another medically necessary surgery, for example:
- in a pelvic surgery where a large pannus can obstruct visualization and panniculectomy is needed for adequate exposure
- when a heavy pannus is likely to contribute to postoperative abdominal wound dehiscence
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:
- improving appearance or self-esteem
- treatment of back or neck pain
- minimizing risk of hernia formation or recurrence
- returning to pre-pregnancy shape
- treatment of psychological symptoms
- addressing psychosocial problems
Is panniculectomy covered by Medicare?
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:
- inability to walk normally
- ulceration
- chronic pain
- chronic intertrigo that:
- consistently recurs over three months while receiving appropriate medical therapy, or
- remains refractory to appropriate medical therapy over a period of three months.
Medicare may not cover panniculectomy for the following conditions because it is considered experimental, investigational, and/or not medically necessary for these indications:
- Improving appearance
- Treating back or neck pain
- Repairing diastasis recti or abdominal wall laxity
- Minimizing the risk of hernia formation or recurrence
- Treating psychological or psychosocial complaints
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.
Is panniculectomy covered by Medicaid?
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.
When is abdominoplasty medically necessary?
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:
- Lipoabdominoplasty
- Mini- or modified abdominoplasty
When is repair of diastasis recti 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.
When is excess skin removal 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:
- belt lipectomy
- brachioplasty
- buttock lift
- circumferential body lift
- circumferential lipectomy
- lipoabdominoplasty
- lower body lift
- suction lipectomy
- thigh lift
- torsoplasty
Health plan criteria for panniculectomy and other references
- Aetna Criteria for Abdominoplasty, Suction Lipectomy, and Ventral Hernia Repair
- Anthem Blue Cross Criteria for Panniculectomy and Abdominoplasty
- Anthem Blue Cross Criteria for Cosmetic and Reconstructive Services of the Trunk and Groin
- Blue Cross Blue Shield of North Carolina Criteria for Abdominoplasty, Panniculectomy and Lipectomy
- Cigna Criteria for Panniculectomy and Abdominoplasty
- EmblemHealth Criteria for Abdominoplasty/Panniculectomy
- Harvard Pilgrim Health Care Criteria for Panniculectomy/Removal of Redundant Skin and Subcutaneous Tissue
- Medicaid Criteria for Panniculectomy
- Indiana
- Iowa
- Massachusetts
- Montana
- Medicare Local Coverage Determination on Cosmetic and Reconstructive Surgery
- Premera Blue Cross Criteria for Panniculectomy and Excision of Redundant Skin
- Tricare Criteria for Reconstructive Surgery
- Tufts Health Plan Medical Necessity Guidelines for Reconstructive and Cosmetic Surgery
- UnitedHealthcare Criteria for Panniculectomy and Body Contouring Procedures
- WellCare Criteria for Panniculectomy and Abdominoplasty