​Latest Review Date: May 2024

Category: Surgery                                                      

POLICY:

Excision of excessive skin and/or subcutaneous tissue of the following areas is considered not medically necessary as this is considered cosmetic:

• Thigh, leg, hip, buttock, arm, forearm or hand, submental fat pad,
• Females- labia minora reduction, labia major reshaping, clitoral reduction, hymenoplasty, pubic liposuction, vaginal rejuvenation or tightening
• Males- phalloplasty, scrotoplasty

Panniculectomy of the abdomen may be considered medically necessary when ALL of the following conditions are met:

• The panniculus fold(s) hangs below the level of the pubis with photo documentation; AND 
• Clinical records and photos document the presence of symptomatology such as chronic intertrigo, excoriation, infection, etc., for which 3 months of conservative treatment has been tried; AND
• There is difficulty with the activities of daily living, such as ambulation, and personal hygiene

Panniculectomy is considered not medically necessary when the following conditions exist:

• As an adjunct to other medically necessary procedures, including but not limited to hysterectomy; unless the medical criteria is met
• For the treatment of back pain
• For the purpose of improving appearance (cosmetic)
• For improving abdominal wall laxity (tummy tuck, cosmetic) or diastasis recti
• For the treatment of psychological or psychosocial complaints
• Suction-assisted lipectomy when performed as the only procedure

Abdominoplasty, a surgical procedure that tightens a lax abdominal wall muscle and removes excess fat and abdominal skin, is considered not medically necessary as this is considered cosmetic and not functional. 

Lipectomy, a surgical technique used to cut and remove subcutaneous fatty tissue, is considered not medically necessary as this is considered cosmetic.

Umbilical transposition is considered cosmetic.

NOTE: For information on Liposuction (lipectomy) for the treatment of lipedema, refer to medical policy #106 Reconstructive Versus Cosmetic Surgery .

DESCRIPTION OF PROCEDURE OR SERVICE:

Abdominoplasty is a surgical procedure performed to tighten a lax abdominal wall caused by diastasis recti (the separation of the two rectus muscles along the medial line of the abdominal wall) and removes excess fat and abdominal skin.  Abdominoplasty is more commonly known as a “tummy tuck”.  This recontouring of the abdominal wall area is often performed solely to improve the appearance of a protuberant abdomen by creating a flatter, firmer abdomen.  Abdominoplasty is always considered cosmetic as it is not performed for functional improvements.

Panniculectomy is the surgical removal of the overhanging “apron” of redundant skin and fat in the lower abdominal area.  Panniculectomy is different from abdominoplasty, in that abdominoplasty tightens the muscle as well as removes excess skin and fat, but a panniculectomy is performed only to remove excess skin and fat.  A panniculus is often seen in individuals who have had significant weight loss or in those who are morbidly obese.  The panniculus can cause difficulty fitting into clothing, interference with personal hygiene, impaired ambulation and be associated with lower back pain or pain in the panniculus itself.  The redundant skin folds are predisposed to areas of intertrigo, which can give rise to infections of the skin (fungal dermatitis, folliculitis, subcutaneous abscesses) or panniculitis. 

Lipectomy is a surgical technique that is used to cut and remove unwanted fat deposits from specific areas of the body.  These include: chin, neck, upper arms, above the breasts, abdomen, buttocks, hips, thighs, knees, calves and ankles.  It may also be performed in conjunction to further sculpt the abdomen or remove fat from other areas. These are generally considered to be cosmetic procedures.

KEY POINTS:

A literature review was conducted through May 13, 2024.

Summary of Evidence

Abdomen

Abdominoplasty is considered reconstructive when performed to correct or relieve structural defects of the abdominal wall and/or chronic low back pain due to functional incompetence of the anterior abdominal wall. These conditions may be caused by: Permanent over stretching of the anterior abdominal wall following one or more pregnancies; Permanent over stretching (with or without diastasis recti of the anterior abdominal wall with a large or long abdominal panniculus) following weight loss in the treatment of morbid obesity and resulting in the uncontrollable intertrigo and/or difficult ambulation and interference with personal hygiene; Trauma or surgery to the anterior wall of the abdomen resulting in loss of fascial integrity or pain from scar contracture; Abdominal hernia following previous abdominal surgery. When an abdominoplasty 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 in nature.

The current medical evidence addressing the efficacy of panniculectomy consists mostly of individual case reports and review articles. The evidence base includes a limited number of small- controlled trials. . However, there is adequate clinical opinion to support the use of this procedure in some circumstances where an individual's health is compromised.

Evidence is 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.

Fischer and colleagues conducted a large retrospective database analysis to assess the additional risk of ventral hernia repair and panniculectomy compared with hernia repair alone (n=55,537). The study authors found that individuals who underwent the combined procedure were significantly at risk for wound complications (P<0.001); venous thromboembolism (P=0.044); reoperation (P<0.001); and overall medical morbidity (P<0.001).

There is little evidence to demonstrate 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 evaluating 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 (ASPS Practice Parameter, 2007b).

Surgical procedures to correct diastasis recti are not effective for alleviating back pain or other non-cosmetic conditions. 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 death.

Non-abdomen

Brachioplasty is a surgical procedure used to remove excess fat and skin from the back of the upper arm. This procedure is primarily to improve a patient’s appearance. Buttock and thigh lifts are surgical procedures used to remove excess fat and skin from the buttocks and thighs. These procedures are intended to enhance the appearance and have no known medical benefits even if done following significant weight loss.

A wide variety of procedures have been proposed to alter the appearance, size, or function of the external and internal female genitalia. Surgical procedures to alter the size or shape of the labia or clitoris restore the hymen, and other such measures do not provide any physical health benefits.

The labia minora is part of the external structure of the vagina. In some patients the labia minora may be enlarged or asymmetrical leading to mild discomfort with wearing certain clothing or during some activities. Reconstructive surgical procedures have been proposed to reduce enlarged labia minora. These procedures have not been well studied in the medical literature and the possible risks have not been adequately assessed in relation to the potential benefits.

Phalloplasty is a surgical procedure to reconstruct or enlarge the penis. Reconstruction may be required in cases of traumatic injury or loss due to disease. Enlargement may be desired in cases of abnormally small penis size.

APPROVED BY GOVERNING BODIES:

Not applicable.

Practice Guidelines and Position Statements

American Society of Plastic Surgeons (ASPS)

The American Society of Plastic Surgeons (ASPS) Practice Parameter for Surgical Treatment of Skin Redundancy for Obese and Massive Weight Loss Patients (2007b) recommends that body contouring surgery, including panniculectomy, be performed only after an individual maintains a stable weight for two to six months. For individuals who are post -bariatric surgery, this is reported to occur 12 to 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. Weight loss and BMI are important when considering panniculectomy and a significant amount of weight loss may not bring the BMI of an individual to less than 30 kg/m2; however a panniculectomy may still be necessary (Arthurs, 2007).

The American Society for Metabolic and Bariatric Surgery (ASMBS)

The American Society for Metabolic and Bariatric Surgery Consensus statement states weight loss can vary from about 25% to 70% of an individual's excess body weight depending on the type of bariatric surgery that is performed (Buchwald, 2005).

KEY WORDS:

Abdominoplasty, panniculectomy, lipectomy, thighplasty, tummy tuck, brachioplasty, panniculus, hip-plasty, labial reduction, phalloplasty, scrotoplasty, labioplasty, vaginoplasty, lipoplasty, liposuction, Umbilical transposition

BENEFIT APPLICATION:

Coverage is subject to member’s specific benefits.  Group-specific policy will supersede this policy when applicable.

ITS: Home Policy provisions apply

FEP: Special benefit consideration may apply. Refer to member’s benefit plan.  

CURRENT CODING: 

CPT Codes

REFERENCES:

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. American Society of Plastic Surgeons.  Treatment of skin redundancy following massive weight loss. www.plasticsurgery.org/Documents/medical-professionals/health-policy/evidence-practice/Surgical-Treatment-of-Skin-Redundancy-Following-Massive-Weight-Loss.pdf.
3. American Society of Plastic Surgeons. Abdominoplasty. www.plasticsurgery.org/Documents/medical-professionals/health-policy/evidence-practice/AbdominoplastyAndPanniculectomy.pdf.
4. 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.
5. 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.
6. Brown M, Adenuga P, Soltanian H. Massive Panniculectomy in the Super Obese and Super-Super Obese: Retrospective Comparison of Primary Closure versus Partial Open Wound Management. Past Reconstr Surg. 2014 Jan; 133(1):32-39.
7. Cadwell JB, Ahsanuddin S, Ayyala HS, Ignatiuk A. Panniculectomy Outcomes by Body Mass Index: an Analysis of 12,732 Cases. Obes Surg. 2021;31(8):3660-3666.
8. Cassar K, Munro A. Surgical treatment of incisional hernia. Br J Surg. 2002; 89(5):534-545.
9. Evans C, Debord J, Howe H, et al. Massive panniculectomy results in improved functional outcome. Am J Surg. 2014 Mar; 207(3):441-444.
10. 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.
11. 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.
12. Hughes KC. Ventral hernia repair with simultaneous panniculectomy. Ann Surg. 1996; 62(8):678-681.
13. IOM (Institute of Medicine). 2011. Clinical Practice Guidelines We Can Trust. Washington, DC: The National Academies Press.
14. 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.
15. Matory WE, O'Sullivan J, Fudem G, Dunn R. Abdominal surgery in patients with severe morbid obesity. Plast Reconstr Surg 1994; 94(7):976-987.
16. Nahas FX, Augusto SM, Ghelfond C. Should diastasis recti be corrected? Aesth Plas Surg. 1997; 21(4):285-289.
17. Pearl ML, Valea FA, Disilvestro PA, Chalas E. Panniculectomy in morbidly obese gynecologic oncology patients. Int J Surg Investig. 2000; 2(1):59-64.
18. Pestana IA, Campbell D, Fearmonti RM, et al. "Supersize" panniculectomy: indications, technique, and results. Ann Plast Surg. 2014 Oct; 73(4):416-421.
19. Powell JL. Panniculectomy to facilitate gynecologic surgery in morbidly obese women. Obstet Gynecol. 1999 94(4):528-531.
20. 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.
21. Staalesen T1, Elander A, Strandell A, Bergh C. A systematic review of outcomes of abdominoplasty. J Plast Surg Hand Surg. 2012 Sep; 46(3-4):139-144.
22. Tillmanns TD, Kamelle SA, Abudayyeh I, et al. Panniculectomy with simultaneous gynecologic oncology surgery. Gynecol Oncol. 2001; 83(3):518-522.
23. Vastine VL, Morgan RF, Williams GS, et al. Wound complications of abdominoplasty in obese patients. Plast Surg. 1999; 42(1):34-39.
24. Zemlyak AY, Colavita PD, El Djouzi S, et al. Comparative study of wound complications: isolated panniculectomy versus panniculectomy combined with ventral hernia repair. J Surg Res. 2012; 177(2):387-391.

POLICY HISTORY:

Medical Policy Group, July 2002

Medical Policy Administration Committee, July 2002

Available for Comment August 26-October 9, 2002

Medical Policy Group, January 2004

Medical Policy Group, September 2005 (1)

Medical Policy Administration Committee, October 2005

Available for comment October 12-November 28, 2005

Medical Policy Group, December 2006 (1)

Medical Policy Administration Committee, January 2007

Available for comment January 5-February 19, 2007

Medical Policy Group, February 2009 (1)

Medical Policy Group, February 2010 (1)

Medical Policy Administration Committee April 2010

Available for comment April 7-May 21, 2010

Medical Policy Group, September 2010 (1): Photographic documentation was added to the policy

Medical Policy Administration Committee, September 2010

Available for comment September 8-October 22, 2010

Medical Policy Group, January 2011

Medical Policy Group, July 2011 (1): Update to Description related to abdominoplasty and removal of coding; change in Policy related to removal of coverage for lipectomy and clarification of differences between abdominoplasty, panniculectomy and lipectomy

Medical Policy Administration Committee, July 2011

Available for comment July 21 through September 5, 2011

Medical Policy Group, January 2013 (1): Literature review complete, no new references added; no change to policy statement

Medical Policy Group, January 2015 (1): Update to Key Points and References; policy criteria prior to 11/5/2011 removed; no change to policy statement

Medical Policy Group, January 2016 (2): Literature review complete, no new references added; updated Key Words; no change to policy statement.

Medical Policy Group, August 2018 (7): Literature review complete, no new references added; updated Key Words; no change to policy statement.

Medical Policy Group, October 2019 (5): Reviewed by consensus. Updates to Key Points. There is no new published peer-reviewed literature available that would alter the coverage statement in the policy.

Medical Policy Group, November 2019 (5): Updates to Description, Key Points, and References. Policy Statement clarification- added investigational statement, “Lipectomy for the treatment of lipedema is considered not medically necessary and investigational.” Added Keywords: lipedema and liposuction.

Medical Policy Group, June 2021 (5): All information regarding lipedema pulled from this policy. Lipedema information is located in MP#719. Updates to Description, Key Points, Key Words, and References. Policy Statement updated to remove “Lipectomy for the treatment of lipedema is considered not medically necessary and investigational.”

Medical Policy Group, July 2021 (5): Reviewed by consensus. Minor update to policy statement to add clarifying verbiage pertaining to excision of excessive skin and/or subcutaneous tissue. No change to policy intent. There is no new published peer-reviewed literature available that would alter the coverage statement in the policy.

Medical Policy Group, May 2022 (5): Reviewed by consensus. Minor update to Key Points. There is no new published peer-reviewed literature available that would alter the coverage statement in the policy.

Medical Policy Group, May 2023 (5): Reviewed by consensus. Update to Key Points, Key Words, and Benefit Application, and References. Policy Statement updated to include the following statement for clarity: “Umbilical transposition is considered cosmetic.” No change to policy intent. There is no new published peer-reviewed literature available that would alter the coverage statement in the policy.

Medical Policy Group, June 2023 (5): The following note was added for clarity: For information on Liposuction (lipectomy) for the treatment of lipedema, refer to medical policy #106 Reconstructive Versus Cosmetic Surgery. No change to policy statement or intent.

Medical Policy Group, May 2024 (5): Reviewed by consensus. Update to Key Points, and References. No change to Policy Statement. There is no new published peer-reviewed literature available that would alter the coverage statement in the policy.

This medical policy is not an authorization, certification, explanation of benefits, or a contract.  Eligibility and benefits are determined on a case-by-case basis according to the terms of the member’s plan in effect as of the date services are rendered.  All medical policies are based on (i) research of current medical literature and (ii) review of common medical practices in the treatment and diagnosis of disease as of the date hereof. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment.

This policy is intended to be used for adjudication of claims (including pre-admission certification, pre-determinations, and pre-procedure review) in Blue Cross and Blue Shield’s administration of plan contracts.

The plan does not approve or deny procedures, services, testing, or equipment for our members. Our decisions concern coverage only. The decision of whether or not to have a certain test, treatment or procedure is one made between the physician and his/her patient. The plan administers benefits based on the member’s contract and corporate medical policies. Physicians should always exercise their best medical judgment in providing the care they feel is most appropriate for their patients. Needed care should not be delayed or refused because of a coverage determination.

As a general rule, benefits are payable under health plans only in cases of medical necessity and only if services or supplies are not investigational, provided the customer group contracts have such coverage.

The following Association Technology Evaluation Criteria must be met for a service/supply to be considered for coverage:

1. The technology must have final approval from the appropriate government regulatory bodies;

2. The scientific evidence must permit conclusions concerning the effect of the technology on health outcomes;

3. The technology must improve the net health outcome;

4. The technology must be as beneficial as any established alternatives;

5. The improvement must be attainable outside the investigational setting.

Medical Necessity means that health care services (e.g., procedures, treatments, supplies, devices, equipment, facilities or drugs) that a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury or disease or its symptoms, and that are:

1. In accordance with generally accepted standards of medical practice; and

2. Clinically appropriate in terms of type, frequency, extent, site and duration and considered effective for the patient’s illness, injury or disease; and

3. Not primarily for the convenience of the patient, physician or other health care provider; and

4. Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease.