Subject: Panniculectomy/Removal of Redundant Skin and Subcutaneous Tissue

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Tabitha Jefferson
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1 Medical Review Criteria Panniculectmy/ Remval f Redundant Tissue Subject: Panniculectmy/Remval f Redundant Skin and Subcutaneus Tissue Backgrund: Panniculectmy is the remval f a large fld f redundant abdminal skin and subcutaneus tissue. The panniculus can cause varius skin prblems, such as irritatin, rash, inflammatin, ulcers, hygiene issues r hernias as it can hang dwn ver the pubis and grin area. This prcedure may be perfrmed after significant weight lss. Authrizatin: Prir authrizatin is required fr panniculectmy and remval f redundant skin and subcutaneus tissue prvided t members enrlled in cmmercial (HMO, POS, PPO) prducts. Please see HPHC s Breast Surgeries Medical Review Criteria r HPHC Gynecmastia Medical Review Criteria fr criteria related t remval f excess/redundant breast skin/tissue. Plicy and Cverage Criteria: Panniculectmy Harvard Pilgrim Health Care (HPHC) cnsiders panniculectmy prcedures as reasnable and medically necessary when dcumentatin cnfirms ALL the fllwing criteria: Member has achieved weight lss f at least 100 lbs.; AND weight lss has resulted in an cclusive verhanging pannus that cvers the genitals and upper thigh crease, upper r mid-thigh, r knees and belw (Grade 3 r higher n ASPS scale); AND EITHER f the fllwing: Weight lss ccurred fllwing lifestyle changes (including diet and exercise) r medical interventin, and member s weight has been stable fr at least 6 mnths; OR Weight lss ccurred fllwing bariatric surgery, and member s weight has been stable fr at least 18 mnths pst-surgery; AND The pannus directly causes ALL f the fllwing: A physical functinal impairment that interferes with activities f daily living including physical exercise; AND Persistent symptmatic intertriginus ulceratins r maceratins that have been refractry t gd persnal hygiene and several mnths f physician-supervised lcal treatment; AND Dcumentatin must include a detailed descriptin f all physician-supervised skin treatment Recurrent skin infectins (i.e., at least 2 episdes within 12 mnths) that required systemic antibitics, and are directly related t the pannus Dcumentatin must cnfirm episdes are refractry t at least a full curse f antibitic treatment Panniculectmy/Remval f Redundant Tissue Page 1 f 5

2 Frntal and lateral clred phtgraphs (taken when the patient is standing erect) are required, and must demnstrate the degree f the pannus and any related skin cnditins. Nte: Clred phtgraph dcumentatin demnstrating the degree f skin redundancy must be mailed r ed t Harvard Pilgrim Health Care as faxed phtgraphs cannt be utilized in making a determinatin f medical necessity. Remval f Redundant Skin and Subcutaneus Tissue frm Anatmical Areas ther than Breast r Abdmen Remval f redundant skin (e.g., frm thighs, hips, buttcks, and/r arms) is cnsidered medically necessary when dcumentatin cnfirms ALL the fllwing: Weight lss has resulted in significant excess/redundant skin r skin flds; AND Redundant skin and/r skin flds directly cause ALL f the fllwing: A physical functinal impairment that interferes with activities f daily living including physical exercise; AND Persistent symptmatic intertriginus ulceratins r maceratins that have been refractry t gd persnal hygiene and physician-supervised lcal treatment ver a perid f several mnths; AND Dcumentatin must include a detailed descriptin f all physician-supervised skin treatment Recurrent skin infectins (i.e. at least 2 episdes within 12 mnths) that required systemic antibitics, and are directly related t the redundant skin Dcumentatin must cnfirm episdes are refractry t at least a full curse f antibitic treatment Nte: Clred phtgraph dcumentatin demnstrating the degree f skin redundancy must be mailed r ed t Harvard Pilgrim Health Care as faxed phtgraphs cannt be utilized in making a determinatin f medical necessity. Same Day Prcedures Panniculectmies are nt cnsidered medically necessary in cnjunctin t ther medically necessary prcedures (e.g. hysterectmy, hernia repair) unless the abve criteria are met. Under state mandate, Harvard Pilgrim Health Care (HPHC) cnsiders treatment t crrect r repair disturbances f bdy cmpsitin caused by HIV-assciated lipdystrphy syndrme as medically necessary. Medical recrd dcumentatin must cnfirm that treatment is medically necessary fr repairing, crrecting r amelirating the effects f HIV-assciated lipdystrphy syndrme. Exclusins: Harvard Pilgrim Health Care (HPHC) cnsiders panniculectmy prcedures r remval f excess/redundant skin as nt medically necessary fr all ther indicatins. In additin, HPHC des nt cver: Abdminplasty Diastasis recti repair Panniculectmy r remval f excess/redundant skin fr treatment f psychlgical r psychscial issues related t redundant skin Panniculectmy r remval f excess/redundant skin perfrmed at the time f an additinal abdminal r gyneclgical surgery unless criteria abve are met Suctin lipectmy, unless stated in mandate Panniculectmy/Remval f Redundant Tissue Page 2 f 5

3 Surgical remval f redundant skin, r bdy cnturing fr csmetic purpses nly Treatment f neck r back pain Csmetic prcedures t reshape bdy parts t imprve the member s appearance r self-esteem when n physical functinal impairment exists Supprting Infrmatin: A panniculectmy is a surgical prcedure t remve the panniculus r excess skin frm the lwer abdmen. Because it hangs dwn ver the pubis and grin area, the panniculus may cause hindrance in healing and varius skin prblems (e.g. inflammatin, ulcers, skin breakdwn). Panniculectmies may be perfrmed after significant weight lss. Rasmussen et al. (2017) reprted n pstperative utcmes amng patients underging recnstructive panniculectmies at the time f gyneclgic surgery. This was a retrspective review f patients where age, bdy mass index, surgical prcedure, estimated bld lss, wund cmplicatins were assessed. One-way analysis f variance and lgistic regressin were used t evaluate the data frm a ttal f 300 individuals. Cmplicatins included 85 (28.3%) cases f superficial cellulitis and 9 (3.0%) cases f surgical-site infectin. Diabetes, hypertensin and smking were significant predictrs f pstperative wund cmplicatins, as shwn frm the lgistic regressin. The authrs cncluded panniculectmy cmbined with gyneclgic surgery t be safe and effective fr bese individuals with acceptable incidence f wund infectin. Mitn et al. (2013) cnducted a retrspective review f the American Cllege f Surgens Natinal Surgical Quality Imprvement Prgram database fr all individuals underging panniculectmy frm 2006 t Patient demgraphics and 30-day utcmes were assessed frm a ttal f 954 panniculectmies that met inclusin criteria. Risk-adjusted multivariate regressin shwed that underging a panniculectmy by a nn-plastic surgen was a significant predictr f verall pstperative cmplicatins (95% CI, 1.35 t 3.23). Overall, the multivariate regressin analysis shwed that panniculectmies perfrmed by plastic surgens resulted in lwer rates f verall pstperative cmplicatins cmpared with thse perfrmed by nn-plastic surgens. Kulaxuszidis et al. (2012) retrspectively analyzed the clinical curse and utcme f 24 individuals receiving panniculectmies t fllw trends f pstperative cmplicatins. Cmplicatins were categrized as minr r majr based n the individual s needs f readmissin r re-peratin. Cmplex decngestive physical therapy (CDP) was perfrmed fr 4 t 6 weeks preperatively and 2 weeks pstperatively. The authrs fund 12 ut f 16 patients within the CDP grup t have uneventful curse, whereas all nn-cdp patients had at least ne cmplicatin. They cncluded that adequate periperative CDP treatment may reduce early pstperative cmplicatins after resectin f panniculus mrbidus. Guidelines: The American Sciety f Plastic Surgens (ASPS) guidelines recmmend panniculectmies fr bese individuals due t the remval f the large abdminal aprn f fat. Accrding t the ASPS, the severity f abdminal defrmities is graded n the scale belw: Grade 1: Panniculus cvers hairline and mns pubis but nt the genitals Grade 2: Panniculus cvers genitals and upper thigh crease Grade 3: Panniculus cvers upper thigh Grade 4: Panniculus cvers mid-thigh Grade 5: Panniculus cvers knees and belw Panniculectmy/Remval f Redundant Tissue Page 3 f 5

4 Cding: Cdes are listed belw fr infrmatinal purpses nly, and d nt guarantee member cverage r prvider reimbursement. The list may nt be all-inclusive. Deleted cdes and cdes which are nt effective at the time the service is rendered may nt be eligible. CPT Cdes Descriptin Excisin, excessive skin and subcutaneus tissue (includes lipectmy); abdmen, infraumbilical panniculectmy Excisin, excessive skin and subcutaneus tissue (includes lipectmy); thigh Excisin, excessive skin and subcutaneus tissue (includes lipectmy); leg Excisin, excessive skin and subcutaneus tissue (includes lipectmy); hip Excisin, excessive skin and subcutaneus tissue (includes lipectmy); buttck Excisin, excessive skin and subcutaneus tissue (includes lipectmy); arm Excisin, excessive skin and subcutaneus tissue (includes lipectmy); ther area Suctin assisted lipectmy; trunk Suctin assisted lipectmy; upper extremity Suctin assisted lipectmy; lwer extremity Billing Guidelines: Member s medical recrds must dcument that services are medically necessary fr the care prvided. Harvard Pilgrim Health Care maintains the right t audit the services prvided t ur members, regardless f the participatin status f the prvider. All dcumentatin must be available t HPHC upn request. Failure t prduce the requested infrmatin may result in denial r retractin f payment. References: 1. Acarturk TO, Wachtman G, Heil B, Landecker A, Curculas AP, Manders EK. "Panniculectmy as an adjuvant t bariatric surgery." Annals f Plastic Surgery 2004; 53: ASPS Recmmended Insurance Cverage Criteria fr Third-Party Payers: Surgical Treatment f Skin Redundancy fr Obese and Massive Weight Lss Patient Bdy Cnturing Surgical Prcedures Physician s Guide: Panniculectmy (in bese patients). American Sciety f Plastic Surgens Available at: Accessed April 28, Cn D, Gusenff JA, Kannan N, El Khudary SR, Naghshineh N, Rubin JP. "Bdy mass and surgical cmplicatins in the pstbariatric recnstructive patient; Analysis f 511 cases." Annals f Surgery 2009; 249: Cper JM, Paige KT, Beshlian KM, Dwney DL, Thereby RC. "Abdminal panniculectmies: High patient satisfactin despite significant cmplicatin rates." Annals f Plastic surgery 2008; 61: Gurunluglu R. Panniculectmy and Redundant Skin Surgery in Massive Weight Lss Patients. Annals f Plastic Surgery. 2008;61(6): di: /sap.0b013e e Manahan M, Shermak MA. "Massive panniculectmy after massive weight lss". Plastic and Recnstructive Surgery 2006; 117: Massachusetts State Mandate: An Act relative t HIV-assciated lipdystrphy syndrme treatment Available at: Accessed May 22, Panniculectmy/Remval f Redundant Tissue Page 4 f 5

5 9. Kulaxuzidis G, Gerke S, Eisenhardt S et al. An Integrated Therapy Cncept fr Reductin f Pstperative Cmplicatins After Resectin f a Panniculus Mrbidus. Obes Surg. 2011;22(4): di: /s Lcal Cverage Determinatin (LCD): Csmetic and Recnstructive Surgery (L34698). Effective date: 1/1/17. Accessed April 6, Meyerwitz BR, Gruber RP, Laub DR. "Massive abdminal panniculectmy." Jurnal f American Medical Assciatin 1973; 225, Mitn L, Buck D, Gart M, Hanwright P, Wang E, Kim J. A Multivariate Regressin Analysis f Panniculectmy Outcmes. Plast Recnstr Surg. 2013;131(4):604e-612e. di: /prs.0b013e f1f. 13. Panniculectmy fr Treatment f Symptmatic Panniculi. Hayesinc.cm/subscriptin/lgin [via subscriptin nly]. Accessed April 28, Rasmussen R, Patibandla J, Hpkins M. Evaluatin f indicated nn-csmetic panniculectmy at time f gyneclgic surgery. Internatinal Jurnal f Gyneclgy & Obstetrics. 2017;138(2): di: /ijg Shermak MA. "Hernia repair and abdminplasty in gastric bypass patients." Plastic and Recnstructive Surgery 2006; 117: Zannis J, Wd BC, Griffin LP, Knipper E, Marks MW, David LR. "Outcme study f the surgical management f panniculitis." Annals f Plastic Surgery 2012; 68: 194. Summary f Changes: Date Changes 5/18 Annual review; n criteria changes 6/17 Backgrund and References updated. Plicy cverage criteria updated fr panniculectmy and remval f redundant skin. Same day prcedures are an exclusin. Cding was updated. 5/17 Reviewed and reissued 4/16 Minr frmatting edits. 4/15 Prvide simplified descriptin f panniculectmy prcedure. Add links t public (member and prvider) sites. Simplify descriptin f weight lss expectatins (member s weight must be stable fr at least 6 mnths fllwing lifestyle changes r medical interventin, r fr at least 12 mnths fllwing bariatric surgery). Prvide simplified descriptin f when cclusive verhanging pannus meets criteria (kept ftnte re: ASPS Grading). Add cding prfile. Expand Exclusins t include prcedures perfrmed at the time f an additinal abdminal r gyneclgical surgery unless criteria are met, and surgical remval f redundant skin, r bdy cnturing fr csmetic purpses nly. Apprved by Medical Plicy Review Cmmittee: 5/22/18 Reviewed/Revised: 5/11, 5/12, 2/13, 3/14, 4/15, 4/16, 5/17, 6/17, 5/18 Initiated: 7/1/10 Panniculectmy/Remval f Redundant Tissue Page 5 f 5

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