Policy No: FCHN.MP Page 1 of 6 Date Originated: Last Review Date Current Revision Date 7/10/07 06/2014 7/2/14

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1 Page 1 of 6 Date Originated: Last Review Date Current Revision Date 7/10/07 06/2014 7/2/14 SUBJECT: Abdominoplasty, Panniculectomy and Ventral/Incisional Hernia RELATED POLICIES/RELATED DESKTOP PROCEDURES: FCHN.MP Bariatric Surgery POLICY/CRITERIA: Note: Summary Plan Document Benefit Language, including Bariatric Surgery, must be reviewed prior to establishing medical necessity. In some instances Abdominoplasty and Panniculectomy may be a Plan exclusion. For plans that do not cover Bariatric Surgery, Abdominoplasty/Panniculectomy & Ventral/Incisional might be excluded as complications of an uncovered service. Abdominoplasty / Panniculectomy 1. Abdominoplasty / panniculectomy may be considered medically necessary when ALL of the following criteria are met: a. The panniculus hangs to or below the level of the pubis b. The panniculus is well documented in the medical record to cause skin irritation or infection resulting in pain, ulceration, suprapubic intertrigo, monilial infestation for at least a 3 month period, in spite of active conservative treatment. Conservative treatment includes antifungal, antibiotic, and moisture-absorbing agents, and other mechanical measures. 2. Abdominoplasty / panniculectomy are considered cosmetic when the above criteria are not met. 3. Abdominoplasty / panniculectomy are considered experimental and investigational for minimizing the risk of hernia formation or recurrence. Medical Policy is developed with consideration given to evidence-based standards of care, community practitioner input and regulatory requirements. Medical Policy is designed to assist in administering contractually defined benefits, and is not intended to offer medical advice or replace medical judgment. Reimbursement is dependent on eligibility and specific benefits, limitations, and exclusions as defined in the Plan Document. In the event of a discrepancy between Medical Policy and the language of the Plan Document, the Plan Document prevails. In the event of a discrepancy between either the Medical Policy or the Plan Document and a regulatory mandate, the regulatory mandate prevails. Treating providers are solely responsible for any medical advice and treatment they provide or recommend.

2 Page 2 of 6 Ventral Hernia 1. Repair of a true ventral hernia is medically necessary when the fascial defect is substantiated by documentation that reflects a true ventral hernia. This documentation might take the form of a physical exam or imaging study that offers information about the location of the hernia, and about whether or not the hernia is accompanied by pain or other symptoms. Some estimate of the size of the hernia should be requested, but it is not required. Note: there should be no coding or other descriptors that would suggest the surgery is an abdominoplasty or cosmetic in nature. DOCUMENTATION REQUESTED: Abdominoplasty / Panniculectomy 1. Letter of request describing the current clinical circumstances justifying the specific procedure being proposed. 2. Clinical records that include the criteria outlined above: Photographic evidence which demonstrates the criteria including the extent of the panniculus and the skin lesions which are described if any. Medical records which document previous treatment and qualifying dermatologic conditions or infections. Ventral Hernia 1. Letter of request describing the current clinical circumstances justifying the specific procedure being proposed. 2. Office Notes indicating: the size of the hernia (not required) whether the ventral hernia is reducible whether the hernia is accompanied by pain or other symptoms BACKGROUND: Abdominoplasty / Panniculectomy Panniculectomy is a surgical procedure to remove a panniculus. In some patients this apron can be associated with skin irritation and infection and interfere with proper hygiene and result in constant skin to skin contact in the folds underneath the panniculus. The panniculus may also interfere with activities of daily living.

3 Page 3 of 6 Panniculectomy may be proposed by itself or in conjunction with other medically necessary or cosmetic procedures such as the repair of a ventral hernia (medically necessary) or abdominoplasty (generally cosmetic). Abdominoplasty is a surgical procedure in which excess skin and fat are removed and the muscles of the abdomen are tightened. The procedure can improve cosmesis by reducing the protrusion of the abdomen. However, abdominoplasty is considered to be cosmetic because it is not associated with functional improvements. Often abdominoplasty is proposed in conjunction with correction of diastasis recti. Repair of a diastasis recti, defined as a thinning out of the anterior abdominal wall fascia, not medically necessary because, according to the clinical literature, it does not represent a true hernia and is of no clinical significance. With increasing use of bariatric surgery and subsequent weight loss requests for paniculectomies have become more common. It is essential to review the Summary Plan Document carefully for specific exclusions and definitions. Some plans specifically exclude certain reconstructive procedures. Ventral Hernia The primary cause of ventral hernia formation is an abdominal wall defect or weakness. A true hernia repair involves opening fascia and/or dissection of a hernia sac with return of intraperitoneal contents back to the peritoneal cavity. A true hernia repair should not be confused with diastasis recti repair, which is part of a standard abdominoplasty. A ventral hernia may be embedded in a panniculus and a panniculectomy may be a necessary adjunct to the ventral hernia repair to reconstruct the abdominal wall. RELATED CODES: NOTE: THIS LIST MAY NOT BE ALL INCLUSIVE OF APPLICABLE CODES. INCLUSION IN THIS LIST DOES NOT NECESSARILY IMPLY COVERAGE CPT Panniculectomy (functional or cosmetic) Excision, excessive skin and subcutaneous tissue (includes lipectomy, abdomen, infra umbical panniculectomy Abdominoplasty (Cosmetic) Excision, excessive skin and subcutaneous tissue (includes lipectomy) abdomen (eg, abdominoplasty) (includes umbilical transposition and fascial plication) (List separately in addition to code for primary procedure) (Use in conjunction with (for abdominal wall hernia repair, see ) (to report other abdominoplasty, use 17999) ICD Other open incisional hernia repair with graft or prosthesis Laparoscopic incisional hernia repair with graft or prosthesis

4 Page 4 of Other laparoscopic repair of other hernia of anterior abdominal wall with graft or prosthesis Other and open repair of other hernia of anterior abdominal wall with graft or prosthesis Umbilical hernia with gangrene Ventral hernia with gangrene Unspecified ventral hernia with gangrene Incisional ventral hernia, with gangrene Other ventral hernia with gangrene Hernia of other specified sites, with gangrene Ventral hernia with obstruction Unspecified ventral hernia with obstruction Incisional hernia with obstruction Other ventral hernia with obstruction V50.1 Plastic surgery unacceptable cosmetic appearance Localized adiposity fat pad Lymphedema Abscess- trunk Intertrigo Diastasis recti Panniculitis HCPCS Repair initial incisional or ventral hernia; reducible Repair initial incisional or ventral hernia; incarcerated or strangulated Repair recurrent incisional or ventral hernia; reducible Repair recurrent incisional or ventral hernia; incarcerated or strangulated Implantation of mesh or other prosthesis for open incisional or ventral hernia repair or mesh for closure of debridement for necrotizing soft tissue infection (List separately in addition to code for the incisional or ventral hernia repair) Laparoscopy, surgical, repair, ventral, umbilical, spigelian or epigastric hernia (includes mesh insertion, when performed); reducible Laparoscopy, surgical, repair, ventral, umbilical, spigelian or epigastric hernia (includes mesh insertion, when performed); incarcerated or strangulated Laparoscopy, surgical, repair, incisional hernia (includes mesh insertion, when performed); reducible Laparoscopy, surgical, repair, incisional hernia (includes mesh insertion, when performed); incarcerated or strangulated Laparoscopy, surgical, repair, recurrent incisional hernia (includes mesh insertion, when performed); reducible Laparoscopy, surgical, repair, recurrent incisional hernia (includes mesh insertion, when performed); incarcerated or strangulated

5 Page 5 of 6 REFERENCES: 1. Bonatti H, Hoeller E, Kirchmayer W, et al. Ventral hernia repair in bariatric surgery. Obes Surg. May 2004;14(5): Mast BA. Safety and efficacy of out-patient full abdominoplasty. Ann Plast Surg. March 2005; 54(3): Matarasso A. The male abdominoplasty. Clin Plast Surg. October 2004; 31(4):555-69, v-vi. 4. Robertson JD, de la Torre JI, Gardner PM et al. Abdominoplasty repair for abdominal wall hernias. Ann Plast Surg. July 2003; 51(1): Seugn-Jun O, Thaller SR. Refinements in abdominoplasty. Clin Plast Surg. January 2002; 29(1): vi. 6. Shermak MA. Hernia repair and abdominoplasty in gastric bypass patients. Plast Reconstr Surg. 2006; 117(4): The Socioeconomic Committee. Treatment of Sin Redundancy Following Massive Weight Loss, Recommended Criteria for Third-Party payor Coverage Arlington Heights, IL. 8. Toranto IR. The relief of low back pain with the WRAP abdominoplasty: A preliminary report. Plast Reconstr Surg. 1990; 85(4): Hayes: Medical Technology Directory, Pediatric Bariatric Surgery for Morbid obesity Published: June 7, Updated June Accessed 10/19/ Hayes: Abdominal Panniculectomy Following Significant Weight Loss Published: April 21, First Choice reviewed policies of other entities engaged in making medical necessity and coverage determinations in developing this policy. DEFINITIONS: Abdominoplasty: A procedure involving the removal of excess abdominal skin and/or fat with or without tightening the lax anterior abdominal wall muscles; it may be reconstructive, cosmetic, or may also be known as a tummy tuck. 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.

6 Page 6 of 6 Hernia: The protrusion of an organ or the fascia of an organ through the wall of the cavity that normally contains it. An abdominal ventral hernia involves the anterior abdominal wall, usually above the pelvis. Ventral hernias may occur in an area of weakness caused by an incompletely healed surgical wound; the hernia is then called an incisional hernia. 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. Panniculus: An apron of fat and skin that hangs from the front of the abdomen. Pannus: A hanging flap of tissue. When involving the abdomen, it is called a panniculus and consists of skin, fat, and sometimes contents of the internal abdomen as part of a hernia. Pubis: A part of the pelvic bone that is located in the groin; also called the pubic bone. APPENDICES: None