This document addresses the surgical procedures panniculectomy and abdominoplasty and when they are considered medically necessary, not medically necessary and cosmetic.

Medically Necessary:  In this document, procedures are considered medically necessary if there is a significant physical functional impairment AND the procedure can be reasonably expected to improve the physical functional impairment. 

Cosmetic: In this document, procedures are considered cosmetic when intended to change a physical appearance that would be considered within normal human anatomic variation. Cosmetic services are often described as those that are primarily intended to preserve or improve appearance.

Medically Necessary:

Panniculectomy is considered medically necessary for the individual who meets the following criteria:

1. The panniculus hangs below the level of the pubis (which is documented in photographs); AND
2. The individual has achieved significant weight loss and reached a body mass index (BMI) less than or equal to 30 kg/m^2_, as well as the following:
   • the individual has maintained a stable weight for at least six months; AND
   • if the individual has had bariatric surgery, he/she is at least 18 months post operative; AND
3. One of the following:
   • there are recurrent or chronic rashes, infections, cellulitis, or non-healing ulcers, that do not respond to conventional treatment for a period of 3 months; information must be documented in office visit records; OR
   • there is difficulty with ambulation and interference with the activities of daily living; information must be documented in office visit records.

Panniculectomy is considered medically necessary as an adjunct to a medically necessary surgery when needed for exposure in extraordinary circumstances.

Not Medically Necessary: 

Panniculectomy is considered not medically necessary when the criteria above are not met.

Panniculectomy is considered not medically necessary as an adjunct to other medically necessary procedures, including, but not limited to, hysterectomy, and/or incisional or ventral hernia repair unless the criteria above are met.

Panniculectomy or abdominoplasty, with or without diastasis recti repair, for the treatment of back pain is considered not medically necessary. 

Cosmetic and Not Medically Necessary:

Liposuction is considered cosmetic and not medically necessary for all indications.

Abdominoplasty when done to remove excess skin or fat with or without tightening of the underlying muscles is considered cosmetic and not medically necessary.

Repair of diastasis recti is considered cosmetic and not medically necessary for all indications.

The current medical evidence addressing the efficacy of panniculectomy consists mostly of individual case reports and review articles.  There have been only a very limited number of small-scale controlled trials on the subject.  However, there is adequate clinical opinion to support the use of this procedure in limited circumstances where a patient's health is jeopardized.

Earlier studies by Matory (1994) and Vastine (1999) demonstrated a direct relationship between BMI and operative risk with abdominal surgery and abdominoplasty in obese patients.  In a retrospective cohort series (Arthurs, 2007) of post-bariatric panniculectomy patients (n=126), the only factor that independently predicted postoperative complications after panniculectomy was pre-panniculectomy body mass index (BMI).  Patients with a BMI greater than 25 kg/m² were at nearly three times the risk of postoperative wound complications.  Although patients who experienced a plateau in weight loss at a BMI of 30-35kg/m² did have the largest functional improvement from a panniculectomy, they also experienced the highest risk postoperatively.  In this series, the average weight loss following bariatric surgery prior to panniculectomy was 116 ± 35 lbs.  A limitation of this study is its retrospective design.

Acarturk (2004) compared the surgical outcomes of panniculectomy following bariatric surgery in a retrospective series of 123 patients, mean age 44.5 years.  The outcomes of 21 patients with panniculectomy done at the time of bariatric surgery were compared with the surgical outcomes of 102 patients who waited a time period of 17 ± 11 months to have the panniculectomy performed.  Overall, patients who had panniculectomy simultaneously with bariatric surgery had more complications.  Wound infections were 48% versus 16%, wound dehiscence 33% versus 13%, and there was a higher incidence (24% versus 0 %) of post operative respiratory distress seen in patients with the combined procedures.  There were 3 postoperative deaths in the combined procedure cohort and none in the group that delayed panniculectomy until an average weight loss of 126 ± 59# was achieved.  The authors conclude that an initial period of substantial weight loss prior to the procedure makes panniculectomy safer and more effective.

The American Society of Plastic Surgeons (ASPS) Practice Parameter for Surgical Treatment of Skin Redundancy for Obese and Massive Weight Loss Patients (2007) recommends that body contouring surgery including panniculectomy be performed only after the patient maintains a stable weight for two to six months.  For post bariatric surgery patients, this is reported to occur 12-18 months after surgery when the BMI has reached the 25 kg/m² to 30 kg/m² range (Rubin, 2004).  If performed prematurely, a potential exists for a second panniculus to develop once additional weight loss has occurred and the risks of postoperative complications are increased.

Evidence is currently insufficient to support panniculectomy as a medically beneficial procedure when the above medically necessary criteria are not met. This includes the concurrent use of panniculectomy with other abdominal surgical procedures, such as incisional or ventral hernia repair or hysterectomy, unless the criteria for panniculectomy alone are met.  Although it has been suggested that the presence of a large overhanging panniculus may interfere with the surgery or compromise post-operative recovery, there is insufficient evidence to support the proposed benefits of improved surgical site access or improved health outcomes.

There is little evidence to demonstrate any significant health benefit imparted by abdominoplasty either for diastasis recti or for other indications.  While there is ample literature to illustrate the cosmetic benefits of this procedure, improvements in physical functioning, cessation of back pain and other positive health outcomes have not been demonstrated.  The main body of evidence is limited to individual case reports primarily concerned with the cosmetic outcomes of the surgery.  At this time, there is insufficient evidence to support abdominoplasty for other than cosmetic purposes when done to remove excess abdominal skin or fat, with or without tightening lax anterior abdominal wall muscles [American Society of Plastic and Reconstructive Surgeons (ASPS), 2006b].

Surgical procedures to correct diastasis recti have not been demonstrated to be effective for alleviating back pain or other non-cosmetic conditions.  At this time, there is insufficient evidence to support the use of surgical procedures to correct diastasis recti for other than cosmetic purposes.

The use of liposuction has not been shown in clinical trials to provide additional benefits beyond standard surgical techniques and has been associated with significant complications, including some deaths.

Obesity has been defined by body mass index (BMI), obtained by dividing the weight in kilograms by height in meters squared (kg/m²).  The clinical definition of obesity is BMI that is greater than 30 kg/m^2_, severe obesity is BMI that is greater than 35 kg/m² and morbid obesity is BMI that is greater than 40 kg/m^2_.  The National Institutes of Health (NIH) provides BMI calculation information at their website: http://www.nhlbisupport.com/bmi/.  Bariatric surgery is an effective and relatively safe treatment for morbid obesity.  Many individuals who are post bariatric surgery seek consultation with a plastic surgeon for skin laxity after weight loss.  Panniculectomy is a surgical procedure used to remove a panniculus, which is an "apron" of fat and skin that hangs from the front of the abdomen.  In certain circumstances, this "apron" can be associated with skin irritation and infection due to interference with proper hygiene and constant skin-on-skin contact in the folds underneath the panniculus.  The presence of a panniculus may also interfere with daily activities.

It has been proposed that for certain gynecologic or other medically necessary procedures, such as incisional or ventral hernia repair or hysterectomy, the presence of a large overhanging panniculus may interfere with the surgery or compromise post-operative recovery. Under these circumstances, it has been suggested that concurrent or adjunctive panniculectomy could be reasonable to facilitate the primary procedure. One common argument for this procedure is that the presence of a large panniculus may have negative effects on the ability of a ventral hernia repair to heal properly and may actually cause rupture of suture lines or other complications. However, there is little evidence addressing the proposed benefits of improved surgical site access or improved health outcomes as a result of the concurrent use of panniculectomy for either gynecological or abdominal procedures.

There are similarities between an abdominoplasty and a panniculectomy as both procedures remove varying amounts of abdominal wall skin and fat. Until recently these procedures shared the same American Medical Association (AMA) Current Procedural Terminology (CPT) code. Abdominoplasty typically performed for cosmetic purposes, involves the removal of excess skin and fat from the pubis to the umbilicus or above, and may include tightening of the rectus muscle and creation or transposition of the umbilicus (navel). "Mini" or "modified" abdominoplasties are cosmetic procedures typically performed on individuals with minimal to moderate defect, mild to moderate skin laxity and muscle flaccidity and do not involve muscle tightening above the navel or creation of a new navel.  (American Society of Plastic Surgeons Practice Parameter, 2007)

Abdominoplasty is also used to correct a condition known as diastasis recti, which is a separation between the left and right side of the rectus abdominis muscle, the muscle covering the front surface of the abdomen. This condition is frequently seen in newborns. As the infant develops, the rectus abdominis muscles continue to grow and the diastasis recti gradually disappears. Surgical treatment may be indicated if a hernia develops and becomes trapped in the space between the muscles, although this is extremely rare. Diastasis recti may also be seen in some women during or following pregnancy, especially in women with poor abdominal tone. The abdominal muscles separate because of the increasing pressure of the growing fetus. In such cases, postpartum abdominal exercises to strengthen the musculature may close the diastasis recti.

Liposuction, also known as lipoplasty or suction-assisted lipectomy, is a surgical procedure performed to recontour the  body by removing excess fat deposits that have been resistant to reduction by diet or exercise. This procedure has been used on various locations of the body, including the buttocks, thighs, shin and abdomen. Liposuction does not remove large quantities of fat and is not intended as a weight reduction technique.

Abdominoplasty: 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.

Bariatric Surgery: a variety of surgical procedures designed to treat obesity by either reconstructing the stomach and/or intestines or placing restrictive devices in or on the digestive tract

Cellulitis: a diffuse, spreading inflammation of the deep tissues under the skin, and on occasion muscle, which may be associated with abscess formation

Diastasis recti: a condition characterized by a separation between the left and right side of the rectus abdominis, which is the muscle covering the front surface of the chest (abdomen); a diastasis recti appears as a ridge running down the midline of the abdomen from the bottom of the breastbone to the navel

Hysterectomy: surgical removal of the uterus

Incisional Hernia: a condition where tissues or organs are able to push through a surgical incision or scar

Intertrigo: an inflammation of the top layers of skin caused by moisture, bacteria, or fungi in the folds of the skin

Liposuction: a surgical procedure designed to remove fat from under the skin via a suction device

Panniculectomy: a procedure designed to remove fatty tissue and excess skin (panniculus) from the lower to middle portions of the abdomen

Pubis: a part of the pelvic bone that is located in the groin; also called the pubic bone

The following codes for treatments and procedures applicable to this document are included below for informational purposes.  Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy.  Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage or these services as it applies to an individual member.

When services may be Medically Necessary when criteria are met for panniculectomy:

When services are Not Medically Necessary or Cosmetic and Not Medically Necessary:
For the procedure codes listed above, when the Position Statement indicates that panniculectomy and abdominoplasty are considered not medically necessary or cosmetic and not medically necessary.

When services are Cosmetic and Not Medically Necessary:
When the code describes a procedure indicated in the Position Statement section as cosmetic and not medically necessary.

When services are also Cosmetic and Not Medically Necessary:
When the code describes a procedure indicated in the Position Statement section as cosmetic and not medically necessary.

Peer Reviewed Publications:

1. Acarturk TO, Wachtman G, Heil B, et al. Panniculectomy as an adjuvant to bariatric surgery. Ann Plast Surg. 2004; 53(4):360-366.
2. Arthurs ZM, Cuadrado D, Sohn V, et al. Post-bariatric panniculectomy: pre-panniculectomy body mass index impacts the complication profile. Am J Surg. 2007; 193(5):567-570.
3. Blomfield PI, Le T, Allen DG, Planner RS. Panniculectomy: a useful technique for the obese patient undergoing gynecological surgery. Gynecol Oncol. 1998; 70(1):80-86.
4. Cassar K, Munro A. Surgical treatment of incisional hernia. Br J Surg. 2002; 89(5):534-545.
5. Hopkins MP, Shriner AM, Parker MG, Scott L. Panniculectomy at the time of gynecologic surgery in morbidly obese patients. Am J Obstet Gynecol. 2000; 182(6):1502-1505. 
6. Hughes KC. Ventral hernia repair with simultaneous panniculectomy. Ann Surg. 1996; 62(8):678-681.
7. Matarasso A, Wallach SG, Rankin M, Galiano RD.  Secondary abdominal contour surgery: a review of early and late reoperative surgery. Plast Reconstr Surg. 2005; 115(2):627-632.
8. Matory WE, O'Sullivan J, et al. Abdominal surgery in patients with severe morbid obesity. Plast Reconstr Surg 1994; 94:976-987.
9. Nahas FX, Augusto SM, Ghelfond C.  Should diastasis recti be corrected?  Aesth Plas Surg.  1997; 21:285-289.
10. Pearl ML, Valea FA, Disilvestro PA, Chalas E.  Panniculectomy in morbidly obese gynecologic oncology patients. Int J Surg Investig. 2000; 2(1):59-64.
11. Powell JL. Panniculectomy to facilitate gynecologic surgery in morbidly obese women. Obstet Gynecol. 1999 94(4):528-531.
12. Rubin JP, Nguyen V, Schwentker A. Perioperative management of the post-gastric-bypass patient presenting for body contour surgery. Clin Plast Surg. 2004; 31(4):601-610.
13. Tillmanns TD, Kamelle SA, Abudayyeh I, et al.  Panniculectomy with simultaneous gynecologic oncology surgery. Gynecol Oncol. 2001; 83(3):518-522.
14. Vastine VL, Morgan RF, Williams GS, et al. Wound complications of abdominoplasty in obese patients. Plast Surg. 1999; 42(1):34-39. 

Government Agency, Medical Society, and Other Authoritative Publications:

1. American Society of Plastic and Reconstructive Surgeons (ASPS). ASPS recommended insurance coverage criteria for third-party payers: Surgical treatment of skin redundancy for obese and massive weight loss patients. 2007. Available at: http://www.plasticsurgery.org/Medical_Professionals/Health_Policy_and_Advocacy/Health_Policy_Resources/Recommended_Insurance_Coverage_Criteria.html. Accessed on December 27, 2009.
2. American Society of Plastic and Reconstructive Surgeons (ASPS). Practice parameter for surgical treatment of skin redundancy for obese and massive weight loss patients. 2007. Available at: http://www.plasticsurgery.org/Medical_Professionals/Health_Policy_and_Advocacy/Health_Policy_Resources/Evidence-based_GuidelinesPractice_Parameters.html. Accessed on December 27, 2009.  
3. Coleman WP, Glogau RG, Klein JA, et al. American Academy of Dermatology Guidelines/Outcomes Committee. Guidelines of care for liposuction. J Am Acad Dermatol. 2001; 45(3):438-447.

1. National Library of Medicine. Medical Encyclopedia: Abdominoplasty - series.  Available at: http://www.nlm.nih.gov/medlineplus/ency/presentations/100184_1.htm. Accessed on December 27, 2009. 
2. National Library of Medicine. Medical Encyclopedia: Diastasis recti.  Available at:  http://www.nlm.nih.gov/medlineplus/ency/article/001602.htm. Accessed on December 27, 2009.

Abdominoplasty
Cosmetic Surgery
Diastasis Recti
Liposuction
Panniculectomy
Reconstructive Surgery