National Medical Policy

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1 National Medical Policy Subject: Policy Number: Abdominoplasty/Panniculectomy/Suction- Assisted Lipectomy/Ventral Hernia Repair NMP149 Effective Date*: May 2004 Updated: November 2016 This National Medical Policy is subject to the terms in the IMPORTANT NOTICE at the end of this document For Medicaid Plans: Please refer to the appropriate State s Medicaid manual(s), publication(s), citation(s), and documented guidance for coverage criteria and benefit guidelines prior to applying Health Net Medical Policies The Centers for Medicare & Medicaid Services (CMS) For Medicare Advantage members please refer to the following for coverage guidelines first: Use Source Reference/Website Link National Coverage Determination (NCD) National Coverage Manual Citation X Local Coverage Determination (LCD)* Plastic Surgery: Cosmetic and Reconstructive Surgery: X Article (Local)* Cosmetic vs. Reconstructive Surgery Coverage: Other None Use Health Net Policy Instructions Medicare NCDs and National Coverage Manuals apply to ALL Medicare members in ALL regions. Medicare LCDs and Articles apply to members in specific regions. To access your specific region, select the link provided under Reference/Website and follow the search instructions. Enter the topic and your specific state to find the coverage determinations for your region. *Note: Health Net must follow local coverage determinations (LCDs) of Medicare Administration Contractors (MACs) located Abdominoplasty Nov 16 1

2 outside their service area when those MACs have exclusive coverage of an item or service. (CMS Manual Chapter 4 Section 90.2) If more than one source is checked, you need to access all sources as, on occasion, an LCD or article contains additional coverage information than contained in the NCD or National Coverage Manual. If there is no NCD, National Coverage Manual or region specific LCD/Article, follow the Health Net Hierarchy of Medical Resources for guidance. Health Net, Inc. considers an initial abdominoplasty / panniculectomy / suctionassisted lipectomy medically necessary or medically unnecessary according to the following: Panniculectomy Health Net Inc. considers panniculectomy, with or without abdominoplasty and/or suction-assisted lipectomy, medically necessary for the following: Patients who have undergone substantial weight loss (e.g., bariatric surgery) resulting in an overhanging apron of redundant skin and fat (panniculus) in the lower abdominal area when all of the following clinical criteria are met: The patient s weight has remained stable for a period in excess of six months following a massive weight loss or if the weight loss is the result of bariatric surgery, abdominoplasty/panniculectomy should not be performed until at least months following bariatric surgery and weight has been stable for at least the most recent six months Panniculus hangs to or below the level of the pubis as documented by photographs*; and There is photographic* evidence of any of the following chronic or recurring conditions refractory to appropriate medical therapy (e.g., analgesics, antibacterials, antifungals, cortisone ointments, drying agents, strict attention to hygiene, topically applied skin barriers and supportive garments) for a period of at least 6 months as documented in serial office notes: Intertrigo (bacterial or fungal infections) Cellulitis Folliculitis Panniculitis Skin ulceration Skin/subcutaneous abscesses not responsive to conventional medical therapy including a trial of oral antibiotics and topical therapies Monilial infestation / fungal dermatitis Actual skin necrosis *Note: Preoperative photographs, chin to waist, standing frontal and lateral with hands at sides, and one with the abdominal fold raised to document any reported skin changes are an absolute requirement for determination of medical appropriateness. Note: Abdominal panniculectomy performed in conjunction with a primary abdominal surgical procedure will be considered as part of the primary surgery (e.g., incisional hernia repair). Abdominoplasty Nov 16 2

3 Note: All requests for panniculectomy in conjunction with repair of an incisional, umbilical, epigastric or ventral hernia must be documented by the patient s medical record and CT scan recording the diameter of the fascial defect. Abdominoplasty Health Net, Inc considers abdominoplasty medically necessary according to the following criteria: 1. It is medically necessary only when it is performed in conjunction with a panniculectomy that meets the above criteria; however, as its primary purpose is to reduce the appearance of a protruding abdomen secondary to a diastasis recti, which is not a true hernia and is of no clinical significance, abdominoplasty is considered as part of the panniculectomy and is not a separate procedure 2. It is not medically necessary when performed as the primary procedure, with or without suction-assisted lipectomy, to enhance the patient's appearance, as this is considered cosmetic in nature Note: Endoscopic abdominoplasty or mini-abdominoplasty is not considered medically necessary for any reason. Suction-Assisted Lipectomy Health Net, Inc considers suction-assisted lipectomy (liposuction) medically necessary according to the following criteria: 1. It is medically necessary only when it is performed in conjunction with a panniculectomy that meets the above criteria; however, when its primary purpose is to enhance the patient's appearance, suction-assisted lipectomy is considered cosmetic in nature 2. It is not medically necessary when it is performed as the primary procedure solely to enhance the patient's appearance, as this is considered cosmetic in nature 3. A belt lipectomy, which combines an abdominoplasty with the circumferential excision of skin and fat for patients with circumferential trunk excess, is not medically necessary and, therefore, ineligible for coverage. Note: Health Net, Inc does not consider suction assisted lipoma extraction medically necessary because it has no literature to support it as standard of care. This procedure does not remove the capsule, thus allowing for recurrence. Small lipomas, which make up the vast majority of these benign tumors, are much more readily and easily removed by cold knife excision and "expulsion". Health Net Inc may allow for suction assisted lipoma removal for an exceptional case of a massive tumor or for biopsy in consideration of liposarcoma. Hernia Repair Health Net, Inc considers hernia repair medically necessary when the diameter of the fascial defect of an incisional, umbilical, epigastric or ventral hernia is substantiated by the patient s medical record Note: According to the medical literature, the condition of diastasis recti presents as a weakness or laxity of the anterior abdominal wall; as such, it does not constitute a true hernia; it is not reducible, does not require surgical intervention, and is harmless and clinically insignificant. If it is unclear as whether or not the patient has a true ventral hernia or a diastasis recti, it is reasonable to ask the provider to Abdominoplasty Nov 16 3

4 obtain a CT scan, which should demonstrate the defect in the anterior abdominal wall. Health Net, Inc. considers the use of FlexHD Acellular Dermis for hernia repair as investigational. Although there are ongoing studies, there continues to be insufficient evidence on the efficacy and safety of FlexHD for hernia repair. Specifically, Health Net, Inc does not consider abdominoplasty/ panniculectomy/ suction-assisted lipectomy medically necessary for any of the following: The procedure(s) is performed solely to enhance the patient's appearance, as this is considered cosmetic in nature Permanent overstretching, with or without diastasis recti, of the anterior abdominal wall secondary to massive weight loss or pregnancy resulting in a large pendulous or protruding abdomen without evidence of signs and/or symptoms of clinical or functional abnormalities documented by the patient s medical record or by photographs; or Suction-assisted lipectomy (liposuction) as a primary procedure because it is considered cosmetic Abdominoplasty performed by liposuction only for localized areas of fat deposits Panniculectomy / liposuction performed in the arms and/or legs (e.g., brachioplasty) Correction of low back pain because in most individuals this condition is multifactorial and the primary cause may not be the abdominal panniculus; or Poorly fitting clothes; or Problems with hygiene; or Difficulty exercising Breathing difficulties Trouble bending to put on socks and shoes, and to wash lower extremities Walking, sitting or even eating meals at a table Stretch marks that sometimes open and bleed Patient no longer able to work. Codes Related To This Policy NOTE: The codes listed in this policy are for reference purposes only. Listing of a code in this policy does not imply that the service described by this code is a covered or noncovered health service. Coverage is determined by the benefit documents and medical necessity criteria. This list of codes may not be all inclusive. On October 1, 2015, the ICD-9 code sets used to report medical diagnoses and inpatient procedures have been replaced by ICD-10 code sets. ICD-9 Codes Other candidiasis of other specified sites Candidiasis of unspecified site Umbilical hernia Abdominoplasty Nov 16 4

5 553.2 Ventral hernia Incisional hernia Epigastric hernia Cellulitis, trunk Intertrigo Other specified hypertrophic and atrophic conditions of the skin Panniculitis ICD-10 Codes B37.89 Other sites of candidiasis B37.9 Candidiasis, unspecified K42.0- K42.9 Umbilical hernia K43.0- K43.9 Ventral hernia K46.9 Unspecified abdominal hernia without obstruction or gangrene L Cellulitis of trunk, unspecified L Acute lymphangitis of trunk, unspecified L30.4 Erythema intertrigo L57.4 Cutis laxa senilis L66.4 Folliculitis ulerythematosa reticulata L90.4 Acrodermatitis chronica atrophicans L90.8 Other atrophic disorders of skin L91.8 Other hypertrophic disorders of the skin M79.3 Panniculitis, unspecified CPT Codes Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy Excision, excessive skin and subcutaneous tissue (includes lipectomy), abdomen (e.g. abdominoplasty) (includes umbilical transposition and fascial placation) Repair initial incisional or ventral hernia; reducible Repair initial incisional or ventral hernia; incarcerated or strangulated Repair umbilical hernia, age 5 or older; reducible Repair umbilical hernia, age 5 or older; incarcerated or strangulated CPT Codes NOT Considered Medically Necessary Excision, excessive skin and subcutaneous tissue, including lipectomy; thigh Excision, excessive skin and subcutaneous tissue, including lipectomy; leg Excision, excessive skin and subcutaneous tissue, including lipectomy, hip Excision, excessive skin and subcutaneous tissue, including lipectomy; buttock Excision, excessive skin and subcutaneous tissue, including lipectomy; arm Excision, excessive skin and subcutaneous tissue, including lipectomy; forearm or hand Excision, excessive skin and subcutaneous tissue, including lipectomy; submental fat pad Excision, excessive skin and subcutaneous tissue, including lipectomy; other area Suction assisted lipectomy; trunk Suction assisted lipectomy; head and neck Abdominoplasty Nov 16 5

6 HCPCS Codes N/A Scientific Rationale Update October 2013 Bochicchio et al (2013) compared 2 different acellular dermal matrices in regard to hernia recurrence and complications in patients who present with a large complicated ventral hernia as a result of trauma or emergency surgery. This prospective quasiexperimental time-interrupted series design evaluated the incidence of hernia recurrence in trauma/emergency surgery patients who had a ventral hernia repair with a biologic matrix. From January 2005 to December 2007, 55 patients with a complicated ventral hernia were repaired with AlloDerm (Life Cell Corporation). Beginning in February 2008 to January 2010, 40 patients with the same criteria were repaired with FlexHD (Musculoskeletal Transplant Foundation) and followed prospectively over the following year. The primary outcome for this study was hernia recurrence (functional or real) at 1 year. Other outcomes variables included abdominal laxity, seroma formation, and wound or intra-abdominal infection. There was no significant difference in age, sex, and body mass index between the groups. In addition, there was no significant difference in the mean hernia size and size of the acellular dermis that was inserted. At 1 year postsurgery, all of the AlloDerm patients were diagnosed with recurrence requiring a second formal repair. Eleven patients (31%) whose hernias were repaired with FlexHD were diagnosed with a recurrence requiring a second formal repair. Authors concluded FlexHD appears to have reduced the recurrence and laxity rates while maintaining a similar complication profile compared with AlloDerm in trauma/emergency surgery patients with large complicated ventral hernias. Scientific Rationale Update October 2012 Janfaza et al. (2012) completed a retrospective, single-center, comparative study, and evaluated the efficacy and safety of hernia repair with FlexHD or SurgiMend (n=35) in 25 general surgery patients and 10 trauma patients with complex abdominal wall hernias who were at high risk for complications due to wound contamination or comorbidities. Indications for hernia repair were open abdomen in trauma patients, and intestinal obstruction, colon perforation, and hernia recurrence in general surgery patients. FlexHD was used in 12 patients (mean age 49 years) and SurgiMend was used in 23 patients (mean age 45 years) to repair 34 ventral hernias and 1 flank hernia. Study outcomes included surgical site infections, hernia recurrences, hospital length of stay, and mortality. The biologic mesh was used to bridge the gap of the hernia defect through direct attachment to the fascia or placement in a subfascial plane. Both the hernia dimensions based on transverse diameter and the rates of recurrent hernias were similar in the two groups. Both groups had high rates of contaminated wounds (~ 50%). Patients were followed for 1 year. Compared with the SurgiMend group there were more surgical site infections (50% versus 17%, P=0.03), superficial infections (25% versus 5%, P=0.02), and hernia recurrences (33% versus 5%, P=0.04) in the FlexHD group. Rates of deep infections with mesh involvement were similar between groups (13% and 17%, P=1.0). The incidence of hernia recurrence due to infection was higher in the FlexHD group (50% versus 5%) although the statistical significance was not reported. No patients died. The mean hospital length of stay was similar in the FlexHD (13 days) and SurgiMend (10 days) groups (P=0.50). These data suggest that short-term outcomes, particularly hernia recurrence, were more favorable for hernias treated with SurgiMend than for those treated with FlexHD. This study is limited by weaknesses in its design and inadequate follow-up time. NOTE: The authors had no conflicts of interest. Abdominoplasty Nov 16 6

7 There is currently a Clinical Trial recruiting participants on Comparative Effectiveness Multicenter Trial for Adhesion Characteristics of Ventral Hernia Repair Mesh, ClinicalTrials.gov Identifier number is NCT The proposed study will compare the benefits, harms, and comparative effectiveness of intraperitoneal barrier-coated and non-barrier coated ventral hernia repair (VHR) mesh in reducing adhesions, adhesion-related complications, and adhesiolysis sequelae in actual patient subpopulations and clinical circumstances. A subset of the data will be analyzed to compare the benefits, harms, and comparative effectiveness of the laparoscopic and open approaches to adhesiolysis. A comprehensive array of healthrelated risk factors and patient-centered outcomes will be assessed in the investigators diverse patient population for proper multivariate data analysis. FLEXHD is one of the assigned interventions to be used. The study was last updated on October 31, International Hernia Mesh Registry (IHMR): This prospective, multicenter, observational registry began enrollment in September 2007 with an estimated minimum enrollment of 3500 patients who received a surgically implanted mesh product (synthetic or biologic) for repair of a hernia defect. The primary outcome measures are patient-reported hernia recurrence rates and pain assessment scores for the 5-year duration of the registry. The registry is sponsored by Ethicon Inc. and the estimated completion date is December In 2010, the Canadian Agency for Drugs and Technologies for Health (CADTH) presented a rapid report on the clinical indications, clinical effectiveness, costeffectiveness, and clinical practice guidelines of biologic meshes used as surgical reconstructive materials. They performed a limited literature search applying filters to limit the retrieval to health technology assessments, systematic reviews, metaanalyses, randomized controlled trials, nonrandomized studies, economic studies, and guidelines. Studies were considered for inclusion if they assessed the clinical effectiveness of any biologic mesh material used in a surgical procedure involving humans. The report identified evidence concerning the use of biologic mesh for a wide range of surgical procedures, including inguinal hernia repair as well as other procedures. There was insufficient clinical evidence to assess the comparative efficacy of biologic and synthetic mesh products. The report identified an abundance of varied mesh products available, and an absence of evidence regarding differences in safety and efficacy. The report concluded that there is currently insufficient evidence to clearly establish the place in therapy of biologic mesh products, (i.e., FLEXHD Acellular Dermis). In summary, the available evidence on the efficacy and safety of FlexHD for hernia repair is extremely limited. Factors to consider in relation to complications following hernia repair are infection risk, adhesion risk, recurrence, mesh degradation, serosa, and pain. Firm conclusions on the safety and efficacy of this allograft await evaluation of evidence from ongoing studies that are now in progress. Comparative peer-reviewed studies are needed to determine the potential advantages and relative efficacy and safety of FlexHD versus other biologic or synthetic meshes. Scientific Rationale Update December 2010 According to the American Society of Plastic Surgeons, surgery to remove extensive skin redundancy and fat folds performed solely to enhance a patient's appearance in the absence of any signs or symptoms of functional abnormalities, should be considered cosmetic in nature. In some instances, however, California law requires coverage of surgery to restore normal appearance (please refer to page 12 of the policy for details). An abdominoplasty or panniculectomy may be utilized to treat a Abdominoplasty Nov 16 7

8 wide range of abdominal defects, from purely cosmetic indications to conditions such as the treatment of excess skin following massive weight loss. According to a Practice Parameter from the American Society of Plastic Surgeons, body contouring surgery is ideally performed after the patient maintains a stable weight for two to six months. For post bariatric surgery patients, body contouring surgery is ideally performed months after bariatric surgery or at the 25 kg/mg2 to 30 kg/mg2 weight range. Ortega et al (2010) aimed to quantify the need for panniculectomy after open bariatric surgery and to analyze the postoperative outcomes in a retrospective cohort study. Patients were divided into 2 groups: group DLP, patients who underwent an abdominal panniculectomy alone and group DLP+, those who underwent panniculectomy in association with another surgical procedure. Four hundred fortysix patients underwent open bariatric surgery and 130 patients (29%) subsequently required an abdominal dermolipectomy. Seventy-six percent presented also incisional hernia and 8% presented cholelithiasis. Forty-six percent of patients presented postoperative complications: wound seroma/infection (21%), wound dehiscence due to skin necrosis (13%), and hemorrhage/hematoma (10%) were the most frequent. There were no major complications or mortality. DLP+ was not associated with an increase in complications. The authors concluded after open bariatric surgery, an abdominal panniculectomy is often required. The procedure has a high postoperative morbidity in these patients, although complications are usually mild. There is not an increase in the rate of complications when panniculectomy is associated with other procedures. Arthurs et al (2007) performed a a retrospective cohort study set in a tertiary care center, evaluating 126 post-bariatric panniculectomies performed over a 3-year period. Perioperative and postoperative data were collected through chart review. Descriptive and inferential analyses were performed using SPSS Ninety-six percent of patients were female. Mean age of the population was 42 (+/-12). The average post-bariatric weight loss and pre-panniculectomy weight were 53 (+/-16) kg and 78 (+/-14) kg, respectively. Complication rates were as follows: seroma 17%, hematoma 13%, surgical site infection (SSI) 17%, transfusion 6%, skin breakdown/necrosis 11%, and re-exploration 11%. Forty percent of patients experienced a complication. Using multivariate logistic regression, the investigators evaluated age, pre-panniculectomy body mass index (BMI), American Society of Anesthesiologists (ASA) class, specimen weight, and operative duration; only prepanniculectomy BMI was an independent predictor for developing a postoperative complication (odds ratio 3.3, confidence interval 1.2 to 8.4, P <.01). The investigators concluded post-bariatric patients who have sustained significant weight loss report subjective improvement after panniculectomy. Even though this population has experienced significant weight loss, they are still at an increased risk for postoperative complications. Maximal reduction in BMI should be stressed to these patients in order to reduce their risk of complications following panniculectomy. Scientific Rationale According to the American Society of Plastic Surgeons: Cosmetic surgery is performed to reshape normal structures of the body in order to improve the patient's appearance and self- esteem. Reconstructive surgery is performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease. It is generally performed to improve function, but may also be done to approximate a normal appearance. Abdominoplasty Nov 16 8

9 The panniculus adiposus is a layer of tissue bearing deposits of fat underneath the skin. After significant weight loss in men or women, particularly those with morbid obesity, an overhanging "apron" of redundant skin and fat may develop in the lower abdominal area. Created by the lack of underlying supportive tissue, these redundant skin folds do not respond to weight loss methods or exercise. Panniculectomy may be performed when permanent overstretching of the upper abdominal wall occurs. Panniculectomy is a surgical procedure in which this large, redundant apron of subcutaneous fat and abdominal skin is removed from the lower abdomen. Under most circumstances, panniculectomy is a cosmetic service. However, skin chaffing may be present under the folds sometimes extending down to or below the level of the pubis, which may create an environment favorable to recurrent or non-healing areas of intertrigo (bacterial or fungal infections), which may or may not respond to appropriate therapies. In patients with stable weight who do not respond to conventional medical therapies after a reasonable period of time, it may be necessary to perform a panniculectomy for medical reasons. Moreover, in patients with significant functional impairment, such as considerable difficulty with walking, Panniculectomy may be indicated. Sometimes abdominoplasty is performed concurrently with panniculectomy in order to achieve the best cosmetic result. The main musculature of the abdomen is held together at the anterior midline by a long, triangular structure called the linea alba whose insertion is at the xiphoid process of the sternum, and which extends downward to the pubis. According to the medical literature, the presence of diastasis recti does not automatically imply the presence of a ventral hernia. Abdominoplasty is the surgical procedure which involves tightening of a lax anterior abdominal wall by plication of the anterior rectus sheath and removal and sculpting of the abdominal flap by removal of excess subcutaneous fat and abdominal skin (also referred to as a Tummy Tuck ). This procedure reduces the appearance of a protruding abdomen, giving a flatter, firmer, tighter stomach and thin waist and provides an overall improvement in the person s shape and figure. Men and women who continue to have fat deposits and loose abdominal skin that won t respond to diet and/or exercise or women with slack muscles and skin due to multiple pregnancies or large babies are the usual candidates for this procedure. As such, an abdominoplasty per say is performed solely to enhance a patient's appearance in the absence of any signs or symptoms of functional abnormalities; in other words, this procedure is considered cosmetic in nature. Abdominoplasty can be performed by liposuction only (for localized areas of fat deposit), partial abdominoplasty/ Mini Tummy Tuck (incision in lower abdomen/pubis only) or complete abdominoplasty/ Full Tummy Tuck (incision in lower abdomen/pubis and around the umbilicus). Liposuction may also be performed in conjunction with a Tummy Tuck to further sculpt the abdomen or remove fat from other areas such as the hip. Belt lipectomy, a procedure that combines abdominoplasty with circumferential excision of skin and fat, is often more ideal for patients with circumferential truncal excess. Belt lipectomy improves abdominal contour, abdominal wall laxity, mons pubis ptosis, back rolls, waist contour, and buttocks contour. Initially, the procedure was performed on postweight-reduction patients only, but its indications were extended to three other groups: (1) patients who were 30 to 50 pounds overweight; (2) patients of normal weight who desired a significant overall truncal improvement; and (3) an obese patient with persistent intra-abdominal excess. Suction-assisted lipectomy, or liposuction, is defined as the surgical excision of fatty tissues by means of aspiration cannulas, introduced through small skin incisions, assisted by suction. Tumescent liposuction refers to the refinement of the procedure that involves subcutaneous infiltration of high volumes of crystalloid fluid containing Abdominoplasty Nov 16 9

10 low concentrations of lidocaine and epinephrine followed by suction-assisted aspiration of fat, by using small aspiration cannulas. The term tumescent liposuction specifically excludes the use of any additional anesthesia medications at dosages that have a significant risk for impairing the protective airway reflexes or for suppressing the respiratory drive. It is a method for performing liposuction surgery with the patient under local anesthesia. Liposuction abdominoplasty, liposuction of abdominal subcutaneous tissue deep and superficial to Scarpa's fascia, with excision of excess abdominal skin and, when indicated, plication of the anterior rectus sheath without undermining, is an effective, low-risk approach to minimizing abdominal flap undermining. The technique allows aggressive thinning and "sculpting" of full-thickness abdominal subcutaneous tissue and achieves a natural abdominal contour. It minimizes the creation of "dead space," which often leads to postoperative complications, as well as preserves sensory nerve and blood supply to the abdominal skin. The operation may be performed with the patient under local anesthesia, which probably diminishes the risk for deep vein thrombosis. Moreover, additional procedures can be conducted safely and the postoperative course is short, uneventful, and without restrictions; patients return to normal activity within a week or so. Body contouring technically involves removal of fat, skin, or both. In general, removal of fat only can be performed with fewer scars and a faster recovery. It is usually performed in the younger patient, where the skin is elastic enough to drape normally after removal of even a large amount of fat. In the older patient and after massive weight loss and pregnancy, it is more common that a skin excision needs to be performed in conjunction with the removal of fat. Ventral (incisional) hernias usually occur as a result of inadequate healing of a previous incision or excessive strain at the site of an abdominal wall scar. These hernias can be particularly bothersome due to their high recurrence and complication rates. Many of the factors that lead to the development of incisional hernias persist at the time of a second repair. Some of these factors can be altered during a phase of preoperative preparation, whereas others are lifelong or progressively worsening conditions. Obesity is one of the leading causes of the development of incisional hernias. The bulk associated with a fatty omentum and excessive subcutaneous tissue provides increased strain on the operative wound during early healing. Many of these individuals have an associated loss of muscle mass and tone and therefore possess inadequate strength at the fascial level to compensate for the added strain. An attempt at weight reduction is often recommended before the repair of an incisional hernia, but few patients actually comply with this recommendation to a degree that lowers the risks associated with reoperation. Surgical repair in an obese patient is associated with an increased potential for pulmonary complications, wound infection, pulmonary embolus, and hernia recurrence. The condition of diastasis recti presents as a weakness or laxity of the abdominal wall separating the two rectus muscles along the median line of the abdominal wall. This does not constitute a true hernia; it is not reducible, does not have defined edges, does not require surgical intervention, and is harmless and clinically insignificant. In order to distinguish a ventral hernia repair from a purely cosmetic abdominoplasty, the size of the hernia, whether the ventral hernia is reducible, whether the hernia is accompanied by pain or other symptoms, whether there is a defect (as opposed to mere thinning) of the abdominal fascia all come into consideration. Abdominoplasty Nov 16 10

11 Review History May 11, 2004 May 2006 July 2006 March 2007 August 2008 October 2009 December 2010 September 2011 August 2012 October 2012 October 2013 October 2014 November 2015 November 2016 Medical Advisory Council Update no revisions Update revised to require CT scan only to substantiate ventral hernia when diastasis recti suspected Code updates CA reconstructive surgery law added to Disclaimer Added as documented in the serial notes to the verbiage, There is photographic evidence of any of the following chronic or recurring conditions refractory to appropriate medical therapy Under medical necessity criteria for panniculectomy, removed requirement in first bullet, Documented weight loss greater than 100 lbs. Revised second bullet to state, If the weight loss is the result of bariatric surgery, abdominoplasty/panniculectomy should not be performed until at least months following bariatric surgery and weight has been stable for at least the most recent six months. Code updates. Added Medicare table and link to Medicare LCD regarding Plastic Surgery Update no revisions Update no revisions Update Added FLEXHD Acellular Dermis as investigational for Hernia Repair Update no revisions. Code updates Update no revisions. Code updates Update no revisions. Code updates No changes This policy is based on the following evidence-based guidelines: 1. American Society of Plastic and Reconstructive Surgeons. Position Paper: Abdominoplasty June American Society of Plastic and Reconstructive Surgeons. Position Paper: Treatment of Skin Redundancy Following Massive Weight Loss June, American Society of Plastic and Reconstructive Surgeons. Practice Parameter for Surgical Treatment of Skin Redundancy Following Massive Weight Loss. January Hayes. Health Technology Brief. Panniculectomy for Abdominal Contouring Following Massive Weight Loss. September 19, Updated August 26, Archived October 9, References Update November Hurvitz KA, Olaya WA, Nguyen A, Wells JH. Evidence-based medicine: Abdominoplasty. Plast Reconstr Surg. 2014;133(5): Fisher KA, Olaya WA, Nguyen A, Wells JH. Evidence-based medicine: Abdominoplasty. Plast Reconstr Surg. 2014;133(5): Koolen PG, Ibrahim AM, Kim K, et al. Patient selection optimization following combined abdominal procedures: Analysis of 4925 patients undergoing panniculectomy/abdominoplasty with or without concurrent hernia repair. Plast Reconstr Surg. 2014;134(4):539e-550e. References Update October Aboelatta YA, Abdelaal MM, Bersy NA. The effectiveness and safety of combining laser-assisted liposuction and abdominoplasty. Aesthetic Plast Surg. 2014;38(1): Abdominoplasty Nov 16 11

12 2. Bogdanov-Berezovsky A Acute esophageal dilation mimicking serious pulmonary complication after post-bariatric abdominoplasty. Aesthetic Plast Surg. 01-FEB- 2013; 37(1): Constantine RS, Davis KE, Kentel JM. Aesthet Surg J May 1;34(4): doi: / X Epub 2014 Mar 27.The effect of massive weight loss status, amount of weight loss, and method of weight loss on body contouring outcomes. 4. Danilla S, Longton C, Valenzuela K, et al. Suction-assisted lipectomy fails to improve cardiovascular metabolic markers of disease: A meta-analysis. J Plast Reconstr Aesthet Surg. 2013;66(11): Levesque AY, Daniels MA, Polynice A. Outpatient lipoabdominoplasty: Review of the literature and practical considerations for safe practice. Aesthet Surg J. 2013;33(7): Sodkin M, Mughal M, Al-Hadithy N. J Plast Reconstr Aesthet Surg Aug;67(8): doi: /j.bjps Epub 2014 May 10.National commissioning guidelines: body contouring surgery after massive weight loss. References Update October Bochicchio GV, De Castro GP, Bochicchio KM, et al. Comparison Study of Acellular Dermal Matrices in Complicated Hernia Surgery. J Am Coll Surg Aug 21 References Update August Avella DM, Podany A, Staveley-O Carroll KF, et al. Laparoscopic repair of postesophagectomy diaphragmatic hernias using human acellular dermal matrix. Interact Cardiovasc Thorac Surg. 2011;13(2): Brown CN, Finch JG. Which mesh for hernia repair? Ann R Coll Surg Engl. 2010;92(4): Available at: 3. Canadian Agency for Drugs and Technologies in Health (CADTH). Biological Mesh: A Review of Clinical Indications, Clinical Effectiveness, Cost-Effectiveness, and Clinical Practice Guidelines. Rapid Response Report: Summary with Critical Appraisal. 2010: Clinicaltrials.gov. Comparative Effectiveness Multicenter Trial for Adhesion Characteristics of Ventral Hernia Repair Mesh. ClinicalTrials.gov Identifier: NCT Available at: 5. Janfaza M, Martin M, Skinner R. A preliminary comparison study of two noncrosslinked biologic meshes used in complex ventral hernia repairs. World J Surg. 2012;36(8): Kozlow JH, Beil RJ, Chung KC. Repair of symptomatic forearm hernias using acellular dermal matrix--two case reports. J Hand Surg Am. 2010;35(12): Musculoskeletal Transplant Foundation (MTF). MTF Signs Marketing Agreement With ETHICON, Inc., for FlexHD Acellular Dermal Matrix Musculoskeletal Transplant Foundation (MTF). FlexHD Acellular Dermis [prescribing information] Pollock TA, Pollock H. Progessive Tension Sutures in Abdominoplasty. A Review of 297 Consecutive Cases. Aesthet Surg J Jun Raulo C, Samama CM, Benhamou D, et al. Prevention of operational thromboembolic risk in plastic and aesthetic surgery. Analysis of cases, inquiries of practice and recommendations of professional practices. Ann Chir Plast Esthet Jun 26. [Epub ahead of print]. 11. Staalesen T, Elander A, Strandell A, et al. A systematic review of outcomes of abdominoplasty. J Plast Surg Hand Surg Jul 2. Abdominoplasty Nov 16 12

13 References Update September Colwell AS. Current concepts in post-bariatric body contouring. Obes Surg Aug;20(8): Kitzinger HB, Abayev S, Pittermann A, et al. The Prevalence of Body Contouring Surgery After Gastric Bypass Surgery. Obes Surg Jun Mericli AF, Drake DB. Abdominal contouring in super obese patients: a singlesurgeon review of 22 cases. Ann Plast Surg May;66(5): van der Beek ES, van der Molen AM, van Ramshorst B. Complications after body contouring surgery in post-bariatric patients: the importance of a stable weight close to normal. Obes Facts. 2011;4(1):61-6 References Update December Arthurs ZM, Cuadrado D, Sohn V, et al. Post-bariatric panniculectomy: prepanniculectomy body mass index impacts the complication profile. Am J Surg May;193(5): Cooper JM, Paige KT, Beshlian KM, et al. Abdominal panniculectomies: high patient satisfaction despite significant complication rates. Ann Plast Surg Aug;61(2): 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 Sep;61(3): Leahy PJ, Shorten SM, Lawrence WT. Maximizing the aesthetic result in panniculectomy after massive weight loss. Plast Reconstr Surg Oct;122(4): 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 Aug;200(2): Saxe A, Schwartz S, Gallardo L, et al. Simultaneous panniculectomy and ventral hernia repair following weight reduction after gastric bypass surgery: is it safe? Obes Surg Feb;18(2): Shermak MA, Rotellini-Coltvet LA, Chang D. Seroma development following body contouring surgery for massive weight loss: patient risk factors and treatment strategies. Plast Reconstr Surg Jul;122(1): Zuelzer HB, Ratliff CR, Drake DB. Complications of abdominal contouring surgery in obese patients: current status. Ann Plast Surg May;64(5): References 1. Dumanian GA, Denham W. Comparison of repair techniques for major incisional hernias. Am J Surg. 2003;185(1): Aly AS, Cram AE, Chao M, et al. Belt lipectomy for circumferential truncal excess: The University of Iowa experience. Plast Reconstr Surg. 2003;111(1): Freeman BG. Body Contouring, Abdominoplasty. emedicine:. September 11, Accessed at: 4. Golladay ES. Abdominal hernias. emedicine General Surgery Topic San Francisco, CA: emedicine.com; updated July 9, Available at: 5. Cassar K, Munro A. Surgical treatment of incisional hernia. Br J Surg. 2002;89(5): van Uchelen JH, Werker PM, Kon M: Complications of abdominoplasty in 86 patients. Plast Reconstr Surg 2001 Jun; 107(7): Larson GM. Society of American Gastrointestinal Endoscopic Surgeons (SAGES). Laparoscopic repair of ventral hernia. Primary Care Physician's Resource Center. Santa Monica, CA: SAGES; Abdominoplasty Nov 16 13

14 8. Pitanguy I: Evaluation of body contouring surgery today: a 30-year perspective. Plast Reconstr Surg 2000 Apr; 105(4): ; discussion Ramirez OM: Abdominoplasty and abdominal wall rehabilitation: a comprehensive approach. Plast Reconstr Surg 2000 Jan; 105(1): Baroudi R, Affonso Ferreira CA: Seroma: How to avoid it and how to treat it. Aesth Surg J 1999; 18(6): Rao RB, Ely SF, Hoffman RS: Deaths related to liposuction. N Engl J Med : Shestak KC: Marriage abdominoplasty expands the mini-abdominoplasty concept. Plast Reconstr Surg 1999 Mar; 103(3): ; discussion Elbaz JS, Flageul G, Olivier-Masveyraud F. "Classical" abdominoplasty. Ann Chir Plast Esthet. 1999;44(4): Micheau P, Grolleau JL. Incisional hernia. Patient management. Approach to the future operated patients. Ann Chir Plast Esthet. 1999;44(4): Vastine VL, Morgan RF, Williams GS, et al. Wound complications of abdominoplasty in obese patients. Ann Plast Surg. 1999;42: Cardenas-Camarena L, Gonzalez LE. Large-volume liposuction and extensive abdominoplasty: a feasible alternative for improving body shape. Plast Reconstr Surg. 1998;102: Mohammad JA, Warnke PH, Stavraky W. Ultrasound in the diagnosis and management of fluid collection complications following abdominoplasty. Ann Plast Surg. 1998;41: Schoeller T, Wechselberger G, Otto A, et al. New technique for scarless umbilical reinsertion in abdominoplasty procedures. Plast Reconstr Surg. 1998;102: Cardenas-Camarena L, Gonzalez LE. Large-volume liposuction and extensive abdominoplasty: A feasible alternative for improving body shape. Plast Reconstr Surg. 1998;102(5): Lockwood T. Rectus muscle diastasis in males: Primary indication for endoscopically assisted abdominoplasty. Plast Reconstr Surg. 1998;101(6): Bridenstine JB. Use of ultra-high frequency electrosurgery (radiosurgery) for cosmetic surgical procedures. Dermatol Surg. 1998;24(3): Matarasso A, Matarasso SL. When does your liposuction patient require an abdominoplasty? Dermatol Surg. 1997;23(12): Nahas FX, Augusto SM, Ghelfond C. Should diastasis recti be corrected? Aesthetic Plast Surg. 1997;21(4): O'Brien JJ, Glasgow A, Lydon P. Endoscopic balloon-assisted abdominoplasty. Plast Reconstr Surg. 1997;99(5): No authors listed. Guiding principles for liposuction. The American Society for Dermatologic Surgery, February Dermatol Surg. 1997;23(12): Coleman WP 3rd, Lawrence N. Liposuction. Dermatol Surg. 1997;23(12): No authors listed. Update from the Ultrasonic Liposuction Task Force of the American Society for Dermatologic Surgery. Dermatol Surg. 1997;23(3): Sensoz O, Arifoglu K, Kocer U, et al. A new approach for the treatment of recurrent large abdominal hernias: the overlap flap. Plast Reconstr Surg. 1997;99: Matarasso A. Liposuction as an adjunct to a full abdominoplasty. Plast Reconstr Surg. 1995;95: Eaves FF 3rd, Nahai F, Bostwick J 3rd: Endoscopic abdominoplasty and endoscopically assisted miniabdominoplasty. Clin Plast Surg 1996 Oct; 23(4): ; discussion Lockwood T: The role of excisional lifting in body contour surgery. Clin Plast Surg 1996 Oct; 23(4): Abdominoplasty Nov 16 14

15 32. Apfelberg DB. Results of multicenter study of laser-assisted liposuction. Clin Plast Surg. 1996;23(4): Baroudi R, Moraes M: A "bicycle-handlebar" type of incision for primary and secondary abdominoplasty. Aesthetic Plast Surg 1995 Jul-Aug; 19(4): Core GB, Mizgala CL, Bowen JC 3rd, Vasconez LO: Endoscopic abdominoplasty with repair of diastasis recti and abdominal wall hernia. Clin Plast Surg 1995 Oct; 22(4): Matarasso A: Liposuction as an adjunct to a full abdominoplasty. Plast Reconstr Surg 1995 Apr; 95(5): Baroudi R: Body sculpturing. Clin Plast Surg 1984 Jul; 11(3): Important Notice General Purpose. Health Net's National Medical Policies (the "Policies") are developed to assist Health Net in administering plan benefits and determining whether a particular procedure, drug, service or supply is medically necessary. The Policies are based upon a review of the available clinical information including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the drug or device, evidence-based guidelines of governmental bodies, and evidence-based guidelines and positions of select national health professional organizations. Coverage determinations are made on a case-by-case basis and are subject to all of the terms, conditions, limitations, and exclusions of the member's contract, including medical necessity requirements. Health Net may use the Policies to determine whether under the facts and circumstances of a particular case, the proposed procedure, drug, service or supply is medically necessary. The conclusion that a procedure, drug, service or supply is medically necessary does not constitute coverage. The member's contract defines which procedure, drug, service or supply is covered, excluded, limited, or subject to dollar caps. The policy provides for clearly written, reasonable and current criteria that have been approved by Health Net s National Medical Advisory Council (MAC). The clinical criteria and medical policies provide guidelines for determining the medical necessity criteria for specific procedures, equipment, and services. In order to be eligible, all services must be medically necessary and otherwise defined in the member's benefits contract as described this "Important Notice" disclaimer. In all cases, final benefit determinations are based on the applicable contract language. To the extent there are any conflicts between medical policy guidelines and applicable contract language, the contract language prevails. Medical policy is not intended to override the policy that defines the member s benefits, nor is it intended to dictate to providers how to practice medicine. Policy Effective Date and Defined Terms. The date of posting is not the effective date of the Policy. The Policy is effective as of the date determined by Health Net. All policies are subject to applicable legal and regulatory mandates and requirements for prior notification. If there is a discrepancy between the policy effective date and legal mandates and regulatory requirements, the requirements of law and regulation shall govern. * In some states, prior notice or posting on the website is required before a policy is deemed effective. For information regarding the effective dates of Policies, contact your provider representative. The Policies do not include definitions. All terms are defined by Health Net. For information regarding the definitions of terms used in the Policies, contact your provider representative. Policy Amendment without Notice. Health Net reserves the right to amend the Policies without notice to providers or Members. In some states, prior notice or website posting is required before an amendment is deemed effective. No Medical Advice. The Policies do not constitute medical advice. Health Net does not provide or recommend treatment to members. Members should consult with their treating physician in connection with diagnosis and treatment decisions. No Authorization or Guarantee of Coverage. The Policies do not constitute authorization or guarantee of coverage of particular procedure, drug, service or supply. Members and providers should refer to the Member contract to determine if exclusions, limitations, and dollar caps apply to a particular procedure, drug, service or supply. Policy Limitation: Member s Contract Controls Coverage Determinations. Statutory Notice to Members: The materials provided to you are guidelines used by this plan to authorize, modify, or deny care for persons with similar illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits covered under your contract. The determination of coverage for a particular procedure, drug, service or supply is not based upon the Policies, but rather is subject to the facts of the individual clinical case, terms and conditions of the member s contract, and requirements of applicable laws and regulations. The contract language contains specific terms and Abdominoplasty Nov 16 15

16 conditions, including pre-existing conditions, limitations, exclusions, benefit maximums, eligibility, and other relevant terms and conditions of coverage. In the event the Member s contract (also known as the benefit contract, coverage document, or evidence of coverage) conflicts with the Policies, the Member s contract shall govern. The Policies do not replace or amend the Member s contract. Policy Limitation: Legal and Regulatory Mandates and Requirements The determinations of coverage for a particular procedure, drug, service or supply is subject to applicable legal and regulatory mandates and requirements. If there is a discrepancy between the Policies and legal mandates and regulatory requirements, the requirements of law and regulation shall govern. Reconstructive Surgery CA Health and Safety Code requires health care service plans to cover reconstructive surgery. Reconstructive surgery means surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) To improve function or (2) To create a normal appearance, to the extent possible. Reconstructive surgery does not mean cosmetic surgery," which is surgery performed to alter or reshape normal structures of the body in order to improve appearance. Requests for reconstructive surgery may be denied, if the proposed procedure offers only a minimal improvement in the appearance of the enrollee, in accordance with the standard of care as practiced by physicians specializing in reconstructive surgery. Reconstructive Surgery after Mastectomy California Health and Safety Code requires treatment for breast cancer to cover prosthetic devices or reconstructive surgery to restore and achieve symmetry for the patient incident to a mastectomy. Coverage for prosthetic devices and reconstructive surgery shall be subject to the co-payment, or deductible and coinsurance conditions, that are applicable to the mastectomy and all other terms and conditions applicable to other benefits. "Mastectomy" means the removal of all or part of the breast for medically necessary reasons, as determined by a licensed physician and surgeon. Policy Limitations: Medicare and Medicaid Policies specifically developed to assist Health Net in administering Medicare or Medicaid plan benefits and determining coverage for a particular procedure, drug, service or supply for Medicare or Medicaid members shall not be construed to apply to any other Health Net plans and members. The Policies shall not be interpreted to limit the benefits afforded Medicare and Medicaid members by law and regulation. Abdominoplasty Nov 16 16