Panniculectomy and Related Redundant Skin Surgery/media/f0e73d7c17a4428ba07278736a...reconstructive procedure after weight loss or bariatric surgery is considered medically necessary

Panniculectomy and Related Redundant Skin Surgery

+ Plan refers to Boston Medical Center Health Plan, Inc. and its affiliates and subsidiaries offering health coverage plans to enrolled members. The Plan operates in Massachusetts under the trade name Boston Medical Center HealthNet Plan and in other states under the trade name Well Sense Health Plan.

1 of 13

bmchp.org | 888-566-0008 wellsense.org | 877-957-1300 Medical Policy

Panniculectomy and Related Redundant Skin Surgery Policy Number: OCA 3.722 Version Number: 10 Version Effective Date: 01/01/17

Product Applicability

All Plan+ Products

Well Sense Health Plan New Hampshire Medicaid NH Health Protection Program

Boston Medical Center HealthNet Plan MassHealth Qualified Health Plans/ConnectorCare/Employer Choice Direct Senior Care Options ◊

Notes: + Disclaimer and audit information is located at the end of this document. ◊ The guidelines included in this Plan policy are applicable to members enrolled in Senior Care Options

only if there are no criteria established for the specified service in a Centers for Medicare & Medicaid Services (CMS) national coverage determination (NCD) or local coverage determination (LCD) on the date of the prior authorization request. Review the member’s product-specific benefit documents at www.SeniorsGetMore.org to determine coverage guidelines for Senior Care Options.

Policy Summary

The Plan considers panniculectomy as a reconstructive procedure to be medically necessary when Plan medical criteria are met. Prior authorization is required. It will be determined during the Plan’s prior authorization process if the service is considered medically necessary for the requested indication. See the Plan’s policy, Medically Necessary (policy number OCA 3.14), for the product-specific definitions of medically necessary treatment.

http://www.seniorsgetmore.org/



2 of 13

Description of Item or Service

Panniculectomy: The surgical removal of subcutaneous fatty tissue and a large fold of redundant/ excess skin (panniculus) from the lower to middle portions of the abdomen. The condition may accompany significant overstretching of the lax anterior abdominal wall and often occurs in morbidly obese individuals or following substantial weight loss. Because it can hang down over the pubis and groin, a panniculus may cause various skin problems that are difficult to heal (e.g., irritation, rash, inflammation, skin breakdown, ulcers, hygiene issues) or cause hernias or pain, or it may negatively impact activities of daily living or quality of life, or interfere with respiratory function. The severity of abdominal deformity is graded according to guidelines from the American Society of Plastic Surgeons, as specified below:

Grade 1: Panniculus covers hairline and mons pubis but not the genitals Grade 2: Panniculus covers genitals and upper thigh crease Grade 3: Panniculus covers upper thigh Grade 4: Panniculus covers mid-thigh Grade 5: Panniculus covers knees and below

Medical Policy Statement

Frontal and lateral preoperative photographs may be requested by the Plan during the prior authorization process; photos must be taken when the member is standing erect and must demonstrate the degree of the pannus and any related skin conditions. Panniculectomy as a reconstructive procedure after weight loss or bariatric surgery is considered medically necessary when the following criteria are met and documented in the member’s medical record, as specified below in items 1 through 7:

1. The member’s panniculus is Grade 2 or greater (i.e., hangs below the level of the pubis); AND 2. No more than an additional 20 pound weight loss is anticipated; AND 3. The member has maintained a stable weight within ONE (1) of following applicable time

frames, as specified below in item a or item b: a. The member has maintained a stable weight for at least the most recent six (6) months

when weight loss is secondary to lifestyle changes, including diet and exercise, or medical intervention (without bariatric surgery); OR



3 of 13

b. If the member has had bariatric surgery, BOTH of the following criteria must be met, as specified below in items (1) and (2): (1) The member is at least 18 months post-operative since the bariatric surgery; AND

(2) The member has maintained a stable weight for at least the most recent 12 months

post-surgery when the weight loss is the result of bariatric surgery; AND

3. At least ONE (1) of the following conditions is documented in the member’s medical record, as specified below in item a or item b:

a. Significant difficulty ambulating which is directly related to the panniculus and is interfering

with activities of daily living; OR b. The pannus has resulted in the following, as specified below in criteria in BOTH item (1) and

item (2):

(1) At least 2 episodes in a 12-month period of ONE (1) or more of the following conditions specified below in items (a) through (d):

(a) Cellulitis; OR (b) Infection; OR (c) Intertriginous skin rash (i.e., skin rashes in areas with skin folds which result in

increased friction, temperature, and occlusion); OR (d) Non-healing skin ulceration, skin maceration, or skin necrosis; AND

(2) Documentation of failed treatment for each of the two (2) episodes in the specified

12-month period that included at least ONE (1) of the following treatments for each episode, as specified below in items (a) through (c)

(a) Conventional wound healing interventions (such as debridement) for at least eight (8) weeks under the direct supervision of a treating provider with documentation of no measurable signs of improvement in wound healing; OR

(b) Systematic antibiotics, systematic antifungals, or systemic corticosteroids for at least two (2) weeks; OR

(c) Local or topical antibiotics, antifungals, corticosteroids for at least four (4) weeks

under the direct supervision of a treating provider; AND



4 of 13

4. The member practices good hygiene techniques; AND 5. The patient is a good candidate for surgery; AND 6. The surgery is expected to restore or improve the documented functional deficit; AND 7. The member is 18 years of age or older on the date of service

Limitations

See the Plan’s policy, Cosmetic, Reconstructive, and Restorative Services (policy number OCA 3.69), for the product-specific definitions of cosmetic services/cosmetic surgery, reconstructive and restorative services, and physical functional impairment. Plan Medical Director review is required to determine if a service is reconstructive and restorative rather than cosmetic (e.g., abdominoplasty to close an open primary or secondary wound rather than for cosmetic reasons). The pannus or excess/redundant skin’s impact on the individual’s emotional well-being or mental health is not considered in determining if a physical functional impairment exists.

1. The following procedures are generally considered cosmetic because there is insufficient

evidence in the peer reviewed medical literature to support the medically necessary use of ANY of these procedures, as specified below in items a through f.

a. Abdominal liposuction or suction assisted lipectomy of the abdomen; b. Abdominoplasty; c. Mini abdominoplasty; d. Repair of diastasis recti or abdominal laxity; e. Panniculectomy as an adjunct to other procedures; AND/OR

f. Panniculectomy for the treatment of back pain and/or neck pain, to reduce the risk of

hernia formation or hernia recurrence, or for an indication not specified in this Plan policy and/or when Plan criteria are not met.

2. The surgical removal of redundant skin or body contouring, including brachioplasty, thighplasty

and other body areas, may be considered cosmetic and will require Plan review according to the guidelines specified in the Cosmetic, Reconstructive, and Restorative Services policy referenced above.



5 of 13

3. The Plan requires Medical Director review to determine the medical necessity of a request for panniculectomy for a member less than 18 years of age on the date of service.

4. Liposuction is often an integral part the surgical removal of excessive skin; liposuction is not

separately reimbursed when the member is authorized for panniculectomy.

Definitions

Abdominoplasty: A cosmetic procedure that firms and flattens the abdomen by the placement of transverse suprapubic/lower abdominal and periumbilical incisions. The abdominal skin is then tightened by excising the caudal portion of abdominal skin and creating a new umbilical opening higher up on the skin that has now been stretched downward. In most cases, tightening of the abdominal musculature is also performed by suture plication of the rectus sheaths. Diastasis Recti: A widening of the linea alba with separation of the rectus muscles. The linea alba is a fibrous band running vertically the entire length of the center of the anterior abdominal wall, receiving the attachments of the oblique and transverse abdominal muscles. Lipectomy: A surgical technique that is used to cut and remove unwanted fat deposits from specific areas of the body. It is not a substitute for weight reduction, but is a method of removing localized fat that does not respond to dieting and exercise. A lipectomy may be done for cosmetic reasons or to treat functional impairment. Mini Abdominoplasty: A partial abdominoplasty involving the incision of the lower abdomen only. The procedure is generally performed solely for cosmetic purposes in order to improve the appearance of the abdominal area. Suction Assisted Lipectomy of the Abdomen: Also known as abdominal liposuction, this is a procedure in which excess fat deposits are removed from the trunk using a liposuction cannula with the goal of reshaping the body, thereby improving appearance. This procedure may be performed alone or as one component of an overall abdominoplasty or panniculectomy procedure.

Applicable Coding

The Plan uses and adopts up-to-date Current Procedural Terminology (CPT) codes from the American Medical Association (AMA), International Statistical Classification of Diseases and Related Health Problems, 10th revision (ICD-10) diagnosis codes developed by the World Health Organization and adapted in the United Stated by the National Center for Health Statistics (NCHS) of the Centers for Disease Control under the U.S. Department of Health and Human Services, and the Health Care Common Procedure Coding System (HCPCS) established and maintained by the Centers for Medicare & Medicaid Services (CMS). Because the AMA, NCHS, and CMS may update codes more frequently or at different intervals than Plan policy updates, the list of applicable codes included in this Plan policy is for informational purposes only, may not be all inclusive, and is subject to change without prior



6 of 13

notification. Whether a code is listed in the Applicable Coding section of this Plan policy does not constitute or imply member coverage or provider reimbursement. Providers are responsible for reporting all services using the most up-to-date industry-standard procedure and diagnosis codes as published by the AMA, NCHS, and CMS at the time of the service. Providers are responsible for obtaining prior authorization for the services specified in the Medical Policy Statement section and Limitation section of this Plan policy, even if an applicable code appropriately describing the service that is the subject of this Plan policy is not included in the Applicable Coding section of this Plan policy. Coverage for services is subject to benefit eligibility under the member’s benefit plan. Please refer to the member’s benefits document in effect at the time of the service to determine coverage or non-coverage as it applies to an individual member.

CPT Code Description: Code Covered When Medically Necessary

15830 Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy

CPT Codes Description: Codes Considered Cosmetic and Not Medically Necessary

15832 Excision, excessive skin and subcutaneous tissue (includes lipectomy); thigh

15833 Excision, excessive skin and subcutaneous tissue (includes lipectomy); leg

15834 Excision, excessive skin and subcutaneous tissue (includes lipectomy); hip

15835 Excision, excessive skin and subcutaneous tissue (includes lipectomy); buttock

15836 Excision, excessive skin and subcutaneous tissue (includes lipectomy); arm

15837 Excision, excessive skin and subcutaneous tissue (includes lipectomy); forearm or hand

15838 Excision, excessive skin and subcutaneous tissue (includes lipectomy); submental fat pad

15839 Excision, excessive skin and subcutaneous tissue (includes lipectomy); other area

15847 Excision, excessive skin and subcutaneous tissue (includes lipectomy), abdomen (e.g., abdominoplasty) (includes umbilical transposition and fascial plication)

15876 Suction assisted lipectomy; head and neck

15877 Suction assisted lipectomy; trunk

15878 Suction assisted lipectomy; upper extremity

15879 Suction assisted lipectomy; lower extremity

Clinical Background Information

Panniculectomy is a surgical procedure that removes a large flap or apron of redundant skin and fat (panniculus) between the navel and the pubis that may hang down from the abdomen to cover the pubis, groin, and upper thighs. Abdominoplasty, referred to as a “tummy tuck,” is a procedure involving the removal of excess abdominal skin and fat, with or without tightening lax anterior abdominal wall muscles, and with or without repositioning or reconstruction of the navel. This reshaping of the abdominal wall area is often performed solely to improve the appearance of a



7 of 13

protuberant abdomen by creating a flatter, firmer abdomen. Abdominoplasty and panniculectomy are often performed together to achieve the best cosmetic result. Most abdominoplasty and panniculectomy procedures typically last about 1-4 hours and may require overnight monitoring; however many patients are able to have these procedures in the outpatient setting. Panniculectomy is associated with a high postoperative complication rate ( approximately 40%), although most complications are mild and treatable. The most common complications include disturbances in wound healing and wound infection, hematoma, and seroma. Major complications that require hospitalization or surgical reintervention occur in 10% to 15% of patients. According to the American Society of Plastic Surgeons (ASPS) Practice Parameter for Abdominoplasty and Panniculectomy, the procedures are most commonly performed for cosmetic indications. However, there are reconstructive indications such as abdominal wall defects, irregularities or pain caused by previous pelvic or lower abdominal surgery, umbilical hernias, intertriginous skin conditions and scarring. The ASPS-recommended coverage criteria state that an abdominoplasty or panniculectomy should be considered a reconstructive procedure when performed to correct or relieve structural defects of the abdominal wall. When an abdominoplasty or panniculectomy is performed solely to enhance a patient's appearance in the absence of any signs or symptoms of functional abnormalities, the procedure should be considered cosmetic. The ASPS Practice Parameter for Surgical Treatment of Skin Redundancy Following Massive Weight Loss states that body contouring surgery is ideally performed after the patient maintains a stable weight for two (2) to six (6) months. For post bariatric surgery patients, this often occurs 12 to 18 months after surgery or at a body mass index (BMI) weight range of 25 kg/m2 to 30 kg/ m2 weight range. At the time of the Plan’s most recent policy review, no clinical guidelines were found from the Centers for Medicare & Medicaid Services (CMS) for panniculectomy. Determine if applicable CMS criteria are in effect for panniculectomy in a national coverage determination (NCD) or local coverage determination (LCD) on the date of the prior authorization request for a Senior Care Options member. Bariatric surgery, behavioral therapy for obesity, and/or medical nutrition therapy may or may not be medically necessary for a Medicare beneficiary who is also a candidate for panniculectomy. See the following applicable CMS guidelines for related services: NCD for Bariatric Surgery for Treatment of Morbid Obesity (100.1), NCD for Intensive Behavioral Therapy for Obesity (210.12), and/or NCD for Medical Nutrition Therapy (180.1). Review the Plan medical policies, Medical Nutrition Therapy in the Outpatient or Office Setting (policy number OCA 3.66) and Bariatric Surgery (policy number OCA 3.49), for additional Plan guidelines related to these services. Verify CMS criteria in the applicable NCD, LCD, and/or coverage guidelines in in effect on the date of the prior authorization request for any of these treatments for a Senior Care Options member.

References

Acarturk TO et al. Panniculectomy as an adjuvant to bariatric surgery. Ann Plast Surg. 2004 Oct;53(4):360-6; discussion 367.

http://www.ncbi.nlm.nih.gov/pubmed?term=%22Acarturk%20TO%22%5BAuthor%5D

http://www.ncbi.nlm.nih.gov/pubmed/15385771



8 of 13

American Association of Clinical Endocrinologists (AACE), The Obesity Society (TOS), and the American Society for Metabolic and Bariatric Surgery (ASMBS). Mechanick JI, Kushner RF, Sugerman HJ, et al. AACE/TOS/ASMBS Bariatric Surgery Guidelines. American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery Medical Guidelines for Clinical Practice for the Perioperative Nutritional, Metabolic, and Nonsurgical Support of the Bariatric Surgery Patient. Endocr Pract. 2008;14(Suppl 1):1-83. American Society of Plastic Surgeons (ASPS). ASPS Recommended Insurance Coverage Criteria for Third Party Payors. Abdominoplasty and Panniculectomy Unrelated to Obesity or Massive Weight Loss. 2007. Accessed at: http://www.plasticsurgery.org/for-medical-professionals/legislation-and-advocacy/health-policy-resources/recommended-insurance-coverage-criteria.html

American Society of Plastic Surgeons (ASPS). ASPS Recommended Insurance Coverage Criteria for Third Party Payors. Surgical Treatment of Skin Redundancy for Obese and Massive Weight Loss Patients. 2007. Accessed at: http://www.plasticsurgery.org/for-medical-professionals/legislation-and-advocacy/health-policy-resources/recommended-insurance-coverage-criteria.html American Society of Plastic Surgeons (ASPS). Practice Parameter for Abdominoplasty and Panniculectomy Unrelated to Obesity or Massive Weight Loss. Accessed at: http://www.plasticsurgery.org/Documents/medical-professionals/health-policy/evidence-practice/AbdominoplastyAndPanniculectomy.pdf

American Society of Plastic Surgeons (ASPS). Practice Parameter for Surgical Treatment of Skin Redundancy for Obese and Massive Weight Loss Patients. 2007. Accessed at: http://www.plasticsurgery.org/Documents/medical-professionals/health-policy/evidence-practice/Surgical-Treatment-of-Skin-Redundancy-Following-Massive-Weight-Loss.pdf Apovian CM, Cummings S, Anderson W, Borud L, Boyer K, Day K, Hatchigian E, Hodges B , Patti ME, Pettus M, Perna F, Rooks D, Saltzman E, Skoropowski J, Tantillo MB and Thomason P. Best Practice Updates for Multidisciplinary Care in Weight Loss Surgery. Obesity. Volume 17, Issue 5, pages 871879, May 2009. Article first published online: 6 SEP 2012. DOI: 10.1038/oby.2008.580. Arthurs ZM et al. Post-bariatric panniculectomy: pre-panniculectomy body mass index impacts the complication profile. Am J Surg. 2007 May;193(5):567-70; discussion 570. Buchwald H; Consensus Conference Panel. Consensus conference statement bariatric surgery for morbid obesity: health implications for patients, health professionals, and third-party payers. Surg Obes Relat Dis. 2005; 1(3):371-381. Centers for Medicare & Medicaid Services (CMS). Decision Memo for Bariatric Surgery for the Treatment of Morbid Obesity (CAG-00250R2). June 27, 2012. Accessed at:

http://www.plasticsurgery.org/for-medical-professionals/legislation-and-advocacy/health-policy-resources/recommended-insurance-coverage-criteria.html




http://www.plasticsurgery.org/Documents/medical-professionals/health-policy/evidence-practice/AbdominoplastyAndPanniculectomy.pdf

http://www.plasticsurgery.org/Documents/medical-professionals/health-policy/evidence-practice/AbdominoplastyAndPanniculectomy.pdf

http://www.plasticsurgery.org/Documents/medical-professionals/health-policy/evidence-practice/Surgical-Treatment-of-Skin-Redundancy-Following-Massive-Weight-Loss.pdf

http://www.plasticsurgery.org/Documents/medical-professionals/health-policy/evidence-practice/Surgical-Treatment-of-Skin-Redundancy-Following-Massive-Weight-Loss.pdf



9 of 13

https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=258&fromdb=true Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD) for Bariatric Surgery for Treatment of Morbid Obesity (100.1). Effective February 12, 2009. Accessed at: http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=57&ncdver=3&bc=AAAAgAAAAAAA& Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD) for Intensive Behavioral Therapy for Obesity (210.12). November 29, 2011. Accessed at: https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=353&ncdver=1&NCAId=253&ver=6&NcaName=Intensive+Behavioral+Therapy+for+Obesity&bc=AiAAAAAAIAAA& Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD) for Medical Nutrition Therapy (180.1). Effective Date October 1, 2002. Accessed at: https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=252&ncdver=1&DocID=180.1&SearchType=Advanced&bc=IAAAAAgAAAAAAA%3d%3d& Centers for Medicare & Medicaid Services (CMS). Welcome to the Medicare Coverage Database. Accessed at: https://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx Danby FW, Hazen PG, Boer J. New and traditional surgical approaches to hidradenitis suppurativa.J Am Acad Dermatol. 2015 Nov; 73(5 Suppl 1):S62-5. doi: 10.1016/j.jaad.2015.07.043.

Fischer JP, Tuggle CT, Wes AM, Lovach SJ. Concurrent panniculectomy with open ventral hernia repair has added risk versus ventral hernia repair: an analysis of the ACS-NSQIP database. J Plast Recontr Aesthet Surg. 2014; 67(5):693-701. Gallagher S et al. Obesity, panniculitis, panniculectomy, and wound care: understanding the challenges. J Wound Ostomy Continence Nurs. 2003 Nov;30(6):334-41. Greco JA 3rd, Castaldo ET, Nanney LB, et al. The effect of weight loss surgery and body mass index on wound complications after abdominal contouring operations. Ann Plast Surg. 2008;61(3):235-242. Hayes Medical Technology Directory. Panniculectomy for Treatment of Symptomatic Panniculi. Winifred Hayes, Inc. May 19, 2016. Kyrger ZB et al. Safety issues in combined gynecologic and plastic surgical procedures. Int J Gynaecol Obstet. 2007 Dec;99(3):257-63. Epub 2007 Jul 30.

https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=258&fromdb=true

https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=258&fromdb=true

http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=57&ncdver=3&bc=AAAAgAAAAAAA&

http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=57&ncdver=3&bc=AAAAgAAAAAAA&

https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=353&ncdver=1&NCAId=253&ver=6&NcaName=Intensive+Behavioral+Therapy+for+Obesity&bc=AiAAAAAAIAAA&



https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=252&ncdver=1&DocID=180.1&SearchType=Advanced&bc=IAAAAAgAAAAAAA%3d%3d&



https://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx

http://www.ncbi.nlm.nih.gov/pubmed?term=%22Gallagher%20S%22%5BAuthor%5D





10 of 13

Manahan MA, Shermak MA. Massive panniculectomy after massive weight loss. Plast Reconstr Surg. 2006 Jun;117(7):2191-7; discussion 2198-9. Neaman KC, Hansen JE. Analysis of complications from abdominoplasty: a review of 206 cases at a university hospital. Ann Plast Surg. 2007 Mar;58(3):292-8. Ortega J, Navarro V, Cassinello N, Lledó S. Requirement and postoperative outcomes of abdominal panniculectomy alone or in combination with other procedures in a bariatric surgery unit. Am J Surg. 2010;200(2):235-240. Paletta C, and Jurkiewicz MJ, Pap, GS. Hidradenitis suppurativa. Plastic & Reconstructive Surgery. June 1988. 81(6):1006. Payer M et al. Panniculectomy--an option for people who are morbidly obese. AORN J. 2003 Apr;77(4):782-94; quiz 795, 797-8. Stewart KJ et al. Complications of 278 consecutive abdominoplasties. J Plast Reconstr Aesthet Surg. 2006;59(11):1152-5. Epub 2006 Jul 5. Walgenbach KJ et al. "Marriage" abdominoplasty: body contouring with limited scars combining mini-abdominoplasty and liposuction. Clin Plast Surg. 2004 Oct;31(4):571-81, vi. Wright JD et al. Long-term outcome of women who undergo panniculectomy at the time of gynecologic surgery. Gynecol Oncol. 2006 Jul;102(1):86-91. Epub 2006 Jan 10. Zuelzer HB, Ratliff CR, Drake DB. Complications of abdominal contouring surgery in obese patients: current status. Ann Plast Surg. 2010;64(5):598-604.

Original Approval Date

Original Effective Date* and Version

Number Policy Owner Approved by

Regulatory Approval: N/A Internal Approval: 01/19/11: MPCTAC 02/23/11: QIC

05/01/11 Version 1

Medical Policy Manager as Chair of Medical Policy, Criteria, and Technology Assessment Committee (MPCTAC) and member of Quality Improvement Committee (QIC)

MPCTAC and QIC

*Effective Date for the BMC HealthNet Plan Commercial Product(s): 01/01/12 *Effective Date for the Well Sense Heath Plan New Hampshire Medicaid Product(s): 01/01/13 *Effective Date for the Senior Care Options Product(s): 01/01/16

http://www.ncbi.nlm.nih.gov/pubmed?term=%22Payer%20M%22%5BAuthor%5D


http://www.ncbi.nlm.nih.gov/pubmed?term=%22Stewart%20KJ%22%5BAuthor%5D


http://www.ncbi.nlm.nih.gov/pubmed?term=%22Walgenbach%20KJ%22%5BAuthor%5D



http://www.ncbi.nlm.nih.gov/pubmed?term=%22Wright%20JD%22%5BAuthor%5D





11 of 13

(Policy formerly titled Redundant Skin Surgery Procedure until 04/30/13.)

Policy Revisions History

Review Date Summary of Revisions

Revision Effective Date and Version

Number

Approved by

01/01/12 Added that the surgical removal of redundant skin or body contouring for cosmetic purposes only including brachioplasty, thighplasty and other body areas are considered cosmetic, updated references and coding.

Version 2 01/18/12: MPCTAC 02/08/12: QIC

08/01/12 Off cycle review for Well Sense Health Plan. Revised Summary statement, reformatted Medical Policy Statement, revised Applicable Coding introductory statement, updated code list, revised Limitations statement

Version 3 08/17/12: MPCTAC 09/06/12: QIC

01/01/13 Review for effective date 05/01/13. Revised title, added Definitions section and moved definitions from Description of Item or Service to Definitions section, reformatted clinical criteria in Medical Policy Statement section, revised Limitations section, revised introductory paragraph and table headings in Applicable Coding section. Referenced the following policies: Medically Necessary and Cosmetic, Reconstructive, and Restorative Services. Changed name of policy category from “Clinical Coverage Guidelines” to “Medical Policy.”

05/01/13 Version 4

01/16/13: MPCTAC 02/21/13: QIC

08/14/13 and 08/15/13

Off cycle review for Well Sense Health Plan and merged policy format. Incorporate policy revisions dated 01/01/13 (as specified above) for the Well Sense Health Plan product; these policy revisions were approved by MPCTAC on 01/16/13 and QIC on 02/21/13 for applicable Plan products.

Version 5 08/14/13: MPCTAC (electronic vote) 08/15/13: QIC

01/01/14 Review for effective date 05/01/14. Updated References and Clinical Background Information sections.

05/01/14 Version 6

01/15/14: MPCTAC 02/18/14: QIC



12 of 13

Policy Revisions History

Revised policy title to specify redundant skin surgery related to panniculectomy. Revised criteria in Medical Policy Statement section. Revised Limitations section without changing criteria.

01/01/15 Review for effective date 03/01/15. Updated Definitions and References sections.

03/01/15 Version 7

01/21/15: MPCTAC 02/11/15: QIC

11/25/15 Review for effective date 01/01/16. Updated template with list of applicable products and corresponding notes. Updated language in the Applicable Coding section.

01/01/16 Version 8

11/18/15: MPCTAC 11/25/15: MPCTAC (electronic vote) 12/09/15: QIC

11/25/15 Review for effective date 03/01/16. Revised criteria in the Medical Policy Statement and Limitations sections. Revised Definitions section.

03/01/16 Version 9

11/18/15: MPCTAC 11/25/15: MPCTAC (electronic vote) 12/09/15: QIC

11/01/16 Review for effective date 01/01/17. Revised Description of Item or Service, Clinical Background Information, References, and Reference to Applicable Laws and Regulations sections.

01/01/17 Version 10

11/16/16: MPCTAC 12/14/16: QIC

Last Review Date

11/01/16

Next Review Date

11/01/17

Authorizing Entity

QIC

Other Applicable Policies

Medical Policy - Bariatric Surgery, policy number OCA 3.49 Medical Policy - Cosmetic, Reconstructive, and Restorative Services, policy number OCA 3.69 Medical Policy - Medical Nutrition Therapy in the Outpatient or Office Setting, policy number OCA 3.66 Medical Policy - Medically Necessary, policy number OCA 3.14:



13 of 13

Reference to Applicable Laws and Regulations

78 FR 48164-69. Centers for Medicare & Medicaid Services (CMS). Medicare Program. Revised Process for Making National Coverage Determinations. August 7, 2013. Accessed at: https://www.cms.gov/Medicare/Coverage/DeterminationProcess/Downloads/FR08072013.pdf

Disclaimer Information: +

Medical Policies are the Plan’s guidelines for determining the medical necessity of certain services or supplies for purposes of determining coverage. These Policies may also describe when a service or supply is considered experimental or investigational, or cosmetic. In making coverage decisions, the Plan uses these guidelines and other Plan Policies, as well as the Member’s benefit document, and when appropriate, coordinates with the Member’s health care Providers to consider the individual Member’s health care needs.

Plan Policies are developed in accordance with applicable state and federal laws and regulations, and accrediting organization standards (including NCQA). Medical Policies are also developed, as appropriate, with consideration of the medical necessity definitions in various Plan products, review of current literature, consultation with practicing Providers in the Plan’s service area who are medical experts in the particular field, and adherence to FDA and other government agency policies. Applicable state or federal mandates, as well as the Member’s benefit document, take precedence over these guidelines. Policies are reviewed and updated on an annual basis, or more frequently as needed. Treating providers are solely responsible for the medical advice and treatment of Members.

The use of this Policy is neither a guarantee of payment nor a final prediction of how a specific claim(s) will be adjudicated. Reimbursement is based on many factors, including member eligibility and benefits on the date of service; medical necessity; utilization management guidelines (when applicable); coordination of benefits; adherence with applicable Plan policies and procedures; clinical coding criteria; claim editing logic; and the applicable Plan – Provider agreement.

https://www.cms.gov/Medicare/Coverage/DeterminationProcess/Downloads/FR08072013.pdf