Does blue cross blue shield cover skin removal surgery

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 functional impairment AND the procedure can be reasonably expected to improve the 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. 

The following codes for treatments and procedures applicable to this guideline 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 of these services as it applies to an individual member.

When services are Not Medically Necessary:
For the procedure codes listed above when criteria are not met or for situations designated in the Clinical Indications section as not medically necessary.

Abdominoplasty, liposuction
When services are Not Medically Necessary or Cosmetic and Not Medically Necessary:
For the following procedure codes, or when the code describes a procedure designated in the Clinical Indications section as not medically necessary or cosmetic and not medically necessary.

CPT

15847

Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen (eg, abdominoplasty) (includes umbilical transposition and fascial plication)

15877

Suction assisted lipectomy; trunk [when specified as abdominal liposuction]

17999

Unlisted procedure, skin, mucous membrane and subcutaneous tissue [when specified as other abdominoplasty, excision excessive skin and subcutaneous tissue, including lipectomy, of abdomen]

ICD-10 Procedure

0J080ZZ

Alteration of abdomen subcutaneous tissue and fascia, open approach [when specified as other abdominoplasty, excision excessive skin and subcutaneous tissue, including lipectomy]

0J083ZZ

Alteration of abdomen subcutaneous tissue and fascia, percutaneous approach

0W0F07Z-0W0F0ZZ

Alteration of abdominal wall with/without tissue substitute, open approach [ includes codes 0W0F07Z, 0W0F0JZ, 0W0F0KZ, 0W0F0ZZ]

0W0F37Z-0W0F3ZZ

Alteration of abdominal wall with/without tissue substitute, percutaneous approach [includes codes 0W0F37Z, 0W0F3JZ, 0W0F3KZ, 0W0F3ZZ]

0W0F47Z-0W0F4ZZ

Alteration of abdominal wall with/without tissue substitute, percutaneous endoscopic approach [includes codes 0W0F47Z, 0W0F4JZ, 0W0F4KZ, 0W0F4ZZ]

ICD-10 Diagnosis

All diagnoses

Repair of diastasis recti
When services are Not Medically Necessary or Cosmetic and Not Medically Necessary:
For the following procedure codes, or when the code describes a procedure designated in the Clinical Indications section as not medically necessary or cosmetic and not medically necessary.

The current medical evidence regarding panniculectomy consists mostly of individual case reports, review articles and 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.

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

Acarturk (2004) compared the surgical outcomes of panniculectomy following bariatric surgery in another retrospective series of 123 participants (mean age 44.5 years). The outcomes of 21 participants with panniculectomy performed at the time of bariatric surgery were compared with the surgical outcomes of 102 participants who waited 17 ± 11 months to undergo panniculectomy. Overall, individuals who had panniculectomy simultaneously with bariatric surgery experienced more complications. Wound infections were 48% versus 16%; wound dehiscence 33% versus 13%; and there was a higher incidence (24% versus 0 %) of postoperative respiratory distress in individuals 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 lbs was achieved. The authors concluded that an initial period of substantial weight loss prior to the procedure results in a safer and more effective panniculectomy procedure.

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 2 to 6 months. For individuals who are post-bariatric surgery, 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. 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 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).

A study by Zemlyak and colleagues (2012) reported on a retrospective review of individuals who had panniculectomy alone versus individuals who had panniculectomy and simultaneous ventral hernia repair. There were 143 participants in the panniculectomy/ventral hernia repair group and 42 participants in the panniculectomy group. The rates for incisional complications and interventions between the two groups were not statistically significant. However, after controlling for age, gender, BMI, subcutaneous use of talc, and intraoperative pulse-a-vac irrigation in the multivariate regression analysis, the group that had both panniculectomy and ventral hernia repair was more likely to develop wound cellulitis. The authors note that while panniculectomy with ventral hernia repair reduces the stress on the hernia repair and potentially decreases the recurrence rate, this potential advantage remains to be proven in large comparative studies.

Fischer and colleagues (2014) conducted a large retrospective database analysis to assess the additional risk of ventral hernia repair (VHR) and panniculectomy (PAN) compared with hernia repair alone (n=55,537) using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) data sets. To account for potential selection bias given the non-randomized assignment of concurrent panniculectomy and the retrospective study design, propensity scores were used which yielded two comparable groups, VHR (n=1250) and VHR+PAN (n=1250). The study authors found that individuals who underwent the combined procedure were at significantly higher risk for wound complications (p<0.001), venous thromboembolism (p=0.044), reoperation (p<0.001) and overall medical morbidity (p<0.001). Two notable limitations of this study include that the ACS-NSQIP dataset only includes 30-day outcomes, precluding analysis of long-term differences in the two study groups. Secondly, the dataset did not include details on the type of panniculectomy skin resection or wound closure techniques, therefore propensity matching, and exploratory analysis of these potentially confounding variables was not possible. Nonetheless, at 30-day follow-up in this large retrospective cohort, outcomes of panniculectomy performed with a concurrent ventral hernia repair appear to result in a significant increase in morbidity compared to VHR alone.

Giordano and colleagues (2017) published a retrospective study based on a prospectively maintained database of all consecutive midline abdominal wall reconstructions for an abdominal wall hernia or oncologic defect performed at a single site from 2005-2015. Of 548 consecutive surgeries, 305 individuals (56%) underwent abdominal wall reconstruction alone and 243 (44%) underwent abdominal wall reconstruction with concurrent panniculectomy. The mean follow-up period was 30 months. Prior to propensity matching, individuals with the combined procedure also had a higher number of previous abdominal surgeries and a larger mean abdominal wall defect size. After propensity matching, there were significantly higher incidences of fat necrosis, and surgical site abscess but no significant difference in hernia recurrence at follow-up. Abdominal wall reconstruction with concurrent panniculectomy was associated with higher wound morbidity with no difference in hernia recurrence rates in follow-up.

Nag and colleagues (2021) published results from another systematic review conducted by ACS-NSQIP to determine the benefit, if any, of adding panniculectomy to gynecologic surgery in obese and morbidly obese individuals. In total, 296 individuals were identified from the NSQIP database who fit the search criteria. A statistically significant association was found between the concomitant procedures and adverse outcomes, including superficial infection, wound infection, pulmonary embolism, sepsis, return to operating room, length of operation and length of stay. Furthermore, there was no significant benefit identified across the studies.

Panniculectomy alone or with other abdominal surgical procedures, such as incisional or ventral hernia repair, or hysterectomy, is not clinically appropriate or an effective treatment of obesity. Recent meta-analyses have published mixed results of co-surgical procedures, but the studies lack documentation of a medical indication for removal of the pannus (Prodromidou, 2020; Rasmussen, 2017; Sosin, 2020). Although it has been suggested that the presence of a large overhanging panniculus may interfere with the surgery or compromise post-operative recovery, the presence of a pannus alone is not a medical condition which warrants surgical intervention. Removal of a pannus, for reasons other than those in the criteria for medical necessity is therefore considered cosmetic and not medically necessary.

The literature addressing abdominoplasty and surgical repair of diastasis recti confirms the cosmetic benefits of these procedures. However, improvements in physical functioning, cessation of back pain, and other positive health outcomes have not been demonstrated. Carloni and colleagues conducted a systematic-review (2016) and confirmed that the quality of evidence surrounding abdominoplasty remains low and no standardization of surgical approaches has been established. Winocour (2015) reported results of a study which included 25,478 abdominoplasties and found high complication rates, compared to other cosmetic procedures, especially when abdominoplasty was combined with other procedures. Massenburg (2015) reported outcomes from 2946 abdominoplasties and found 8.5% of subjects were readmitted due to complications and 5% required revision surgery. Salari and colleagues (2021) conducted a systematic-review and meta-analysis to characterize the global prevalence of seroma following abdominoplasty and found the global prevalence following the procedure approaching 11% (95% CI, 9.3-3.6%). At this time, the evidence does not support abdominoplasty when done to remove excess abdominal skin or fat, with or without tightening lax anterior abdominal wall muscles, as an effective treatment for any medical condition, though it is an effective cosmetic procedure (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.

Similarly, the use of liposuction has been shown to produce cosmetic benefits in terms of appearance and body contour, however, liposuction has not been shown to be an effective treatment of obesity or other medical conditions and has been associated with significant complications, including death.

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 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.

Federal and State law, as well as contract language, and Coverage Guidelines take precedence over Clinical UM Guidelines. We reserve the right to review and update Clinical UM Guidelines periodically. Clinical guidelines approved by the Medical Policy & Technology Assessment Committee are available for general adoption by plans or lines of business for consistent review of the medical necessity of services related to the clinical guideline when the plan performs utilization review for the subject. Due to variances in utilization patterns, each plan may choose whether to adopt a particular Clinical UM Guideline. To determine if review is required for this Clinical UM Guideline, please contact the customer service number on the member's card.

Alternatively, commercial or FEP plans or lines of business which determine there is not a need to adopt the guideline to review services generally across all providers delivering services to Plan’s or line of business’s members may instead use the clinical guideline for provider education and/or to review the medical necessity of services for any provider who has been notified that his/her/its claims will be reviewed for medical necessity due to billing practices or claims that are not consistent with other providers, in terms of frequency or in some other manner.

No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying, or otherwise, without permission from the health plan.

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