Description:
Panniculectomy is the surgical removal of hanging excess skin/fat (panniculus, pannus, apron) from the abdomen via a transverse or vertical wedge, but does not include muscle plication, neoumbilicoplasty or flap elevation. The excess abdominal skin and fat may hang down over the genital area and thighs, and rarely to the knees. The excess abdominal skin and fat may be accompanied by laxity of the anterior abdominal wall. According to the American Society of Plastic Surgeons (ASPS), the severity of abdominal deformities is graded as follows:

Grade 1: Panniculus covers hairline and mons pubis but not the genitals

Grade 2: Panniculus covers genitals and upper thigh crease

Grade 3: Panniculus covers upper thigh

Grade 4: Panniculus covers mid-thigh

Grade 5: Panniculus covers knees and below

Abdominoplasty, also referred to as a “tummy tuck,” is an excisional surgical procedure, which involves removal of excess abdominal skin (apron) and fat from the pubis to the umbilical or above, and may include fascial plication of the rectus muscle diastasis and a neoumbilicoplasty. This reshaping and contouring of the abdominal wall area is often performed solely to improve the appearance of a protuberant abdomen by creating a flatter, firmer abdomen. (American Society of Plastic Surgeons (ASPS), 2007)

There are similarities between an abdominoplasty and a panniculectomy procedure, as both procedures remove varying amounts of abdominal wall skin and fat. According to the ASPS Practice Parameter for Abdominoplasty and Panniculectomy (2007), the procedures are most commonly performed for cosmetic indications. However, there are reconstructive indications, such as abdominal wall defects, irregularities or pain caused by previous pelvic or lower abdominal surgery, umbilical hernias, intertriginous skin conditions and scarring. The ASPS recommended coverage criteria state that an abdominoplasty or panniculectomy should be considered a reconstructive procedure when performed to correct or relieve structural defects of the abdominal wall. When an abdominoplasty or panniculectomy is performed solely to enhance a patient's appearance in the absence of signs or symptoms of functional abnormalities, the procedure should be considered cosmetic.

The ASPS Practice Parameter for Surgical Treatment of Skin Redundancy Following Massive Weight Loss (2007) states that "body contouring surgery is ideally performed after the patient maintains a stable weight for two to six months. For post bariatric surgery patients, this often occurs 12 – 18 months after surgery or at the 25 kg/mg2; to 30 kg/mg2; weight range.”

Policy:
Abdominoplasty and Lipectomy are considered cosmetic and NOT MEDICALLY NECESSARY for all applications.

Panniculectomy will be considered MEDICALLY NECESSARY when the medical criteria and guidelines shown below are met.

Panniculectomy or abdominoplasty, with or without diastasis recti repair, for the treatment of back pain is considered NOT MEDICALLY NECESSARY.

Repair of diastasis recti is considered NOT MEDICALLY NECESSARY for all indications.

NOTE: Coverage for panniculectomy is subject to the member’s benefit terms, limitations and maximums. Some plans may exclude coverage for panniculectomy, as the member may not have a benefit for weight loss surgery or a complication of a non-covered service. If a pannus (panniculus) results from a contract-excluded procedure such as bariatric surgery, the panniculectomy will also be considered an excluded procedure.

Refer to specific contract language regarding panniculectomy surgery.

Policy Gudielines:   
A panniculectomy may be considered reconstructive when all of the following criteria are met: 

1. The pannus hangs at or below the level of the pubic symphysis.
2. The pannus causes bacterial cellulitis that:
   • a. Failed to respond or recurred after at least two courses of antibiotic treatment (oral or parenteral).
   • b. Is unresponsive to conservative treatment including adequate hygiene and topical anti-infective medications.
   • c. Results in fibrosis and thickening of the pannus with discoloration and/or lymphedema or peau d’orange effect (pitting or prominence of pores due to fibrosis and swelling) of the overlying skin.

Significant Weight Loss/Bariatric Surgery
Panniculectomy performed following *significant weight loss meets the definition of medical necessity when ALL of the following criteria are met:

• Meets ALL of the criteria listed above under the Panniculectomy heading.
• Symptoms (persistent skin condition under panniculus, chronic maceration of overhanging skin) or functional impairment persists despite *significant weight loss that has been stable for at least three months or documented attempts at weight loss (medically supervised diet or bariatric surgery) have been unsuccessful.
• If the member has had bariatric surgery, he or she is at least 18 months post-operative or has documented stable weight for at least three months.

Note: *Significant weight loss varies based on the member’s clinical circumstances and may be documented when the member:

• Reaches a body mass index (BMI) less than or equal to 30 kg/m2.
• Has documented at least a 100 pound weight loss.
• Has achieved a weight loss that is 40 percent or greater of the excess body weight that was present prior to the member's weight loss or surgical intervention.

Panniculectomy is considered not medically necessary unless the clinical criteria above are met.

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

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 is its retrospective design and small sample population.

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 percent versus 16 percent; wound dehiscence 33 percent versus 13 percent; and there was a higher incidence (24 percent versus 0 percent) of postoperative respiratory distress in individuals with the combined procedures. There were three 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 two to six 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 Concensus statement states weight loss can vary from about 25 percent to 70 percent of an individual's excess body weight, depending on the type of bariatric surgery that is performed (Buchwald, 2005).

Evidence is insufficient to support panniculectomy as a medically beneficial procedure when the above medically necessary criteria are not met. This includes the concurrent use of panniculectomy with other abdominal surgical procedures, such as incisional or ventral hernia repair, or hysterectomy, unless the criteria for panniculectomy alone are met. Although it has been suggested that the presence of a large overhanging panniculus may interfere with the surgery or compromise post-operative recovery, there is insufficient evidence to support the proposed benefits of improved surgical site access or improved health outcomes.

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

There is little evidence to demonstrate significant health benefit imparted by abdominoplasty either for diastasis recti or for other indications. While there is ample literature to illustrate the cosmetic benefits of this procedure, improvements in physical functioning, cessation of back pain and other positive health outcomes have not been demonstrated. The main body of evidence is limited to individual case reports evaluating the cosmetic outcomes of the surgery. At this time, there is insufficient evidence to support abdominoplasty for other than cosmetic purposes when done to remove excess abdominal skin or fat, with or without tightening lax anterior abdominal wall muscles (ASPS Practice Parameter, 2007b).

Surgical procedures to correct diastasis recti are not effective for alleviating back pain or other non-cosmetic conditions. There is insufficient evidence to support the use of surgical procedures to correct diastasis recti for other than cosmetic purposes.

The use of liposuction has not been shown in clinical trials to provide additional benefits beyond standard surgical techniques and has been associated with significant complications, including death.

Definitions:
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.

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

References: 

1. Acarturk TO, Wachtman G, Heil B, et al. Panniculectomy as an adjuvant to bariatric surgery. Ann Plast Surg. 2004; 53(4):360-366.
2. Arthurs ZM, Cuadrado D, Sohn V, et al. Post-bariatric panniculectomy: pre-panniculectomy body mass index impacts the complication profile. Am J Surg. 2007; 193(5):567-570.
3. Blomfield PI, Le T, Allen DG, Planner RS. Panniculectomy: a useful technique for the obese patient undergoing gynecological surgery. Gynecol Oncol. 1998; 70(1):80-86.
4. Cassar K, Munro A. Surgical treatment of incisional hernia. Br J Surg. 2002; 89(5):534-545.
5. Fischer JP, Tuggle CT, Wes AM, Lovach SJ. Concurrent panniculectomy with open ventral hernia repair has added risk versus ventral hernia repair: an analysis of the ACS-NSQIP database. J Plast Recontr Aesthet Surg. 2014; 67(5):693-701.
6. Hopkins MP, Shriner AM, Parker MG, Scott L. Panniculectomy at the time of gynecologic surgery in morbidly obese patients. Am J Obstet Gynecol. 2000; 182(6):1502-1505. 
7. Hughes KC. Ventral hernia repair with simultaneous panniculectomy. Ann Surg. 1996; 62(8):678-681.
8. Matarasso A, Wallach SG, Rankin M, Galiano RD. Secondary abdominal contour surgery: a review of early and late reoperative surgery. Plast Reconstr Surg. 2005; 115(2):627-632.
9. Matory WE, O'Sullivan J, Fudem G, Dunn R. Abdominal surgery in patients with severe morbid obesity. Plast Reconstr Surg 1994; 94(7):976-987.
10. Nahas FX, Augusto SM, Ghelfond C. Should diastasis recti be corrected? Aesth Plas Surg. 1997; 21(4):285-289.
11. Pearl ML, Valea FA, Disilvestro PA, Chalas E. Panniculectomy in morbidly obese gynecologic oncology patients. Int J Surg Investig. 2000; 2(1):59-64.
12. Powell JL. Panniculectomy to facilitate gynecologic surgery in morbidly obese women. Obstet Gynecol. 1999 94(4):528-531.
13. Rubin JP, Nguyen V, Schwentker A. Perioperative management of the post-gastric-bypass patient presenting for body contour surgery. Clin Plast Surg. 2004; 31(4):601-610.
14. Tillmanns TD, Kamelle SA, Abudayyeh I, et al. Panniculectomy with simultaneous gynecologic oncology surgery. Gynecol Oncol. 2001; 83(3):518-522.
15. Vastine VL, Morgan RF, Williams GS, et al. Wound complications of abdominoplasty in obese patients. Plast Surg. 1999; 42(1):34-39. 
16. Zemlyak AY, Colavita PD, El Djouzi S, et al. Comparative study of wound complications: isolated panniculectomy versus panniculectomy combined with ventral hernia repair. J Surg Res. 2012; 177(2):387-391. 
17. American Society of Plastic and Reconstructive Surgeons (ASPS). ASPS recommended insurance coverage criteria for third-party payers: Surgical treatment of skin redundancy for obese and massive weight loss patients. 2007a. Available at:
    http://www.plasticsurgery.org/Medical_Professionals/Health_Policy_and_Advocacy/Health_Policy_Resources/Recommended_Insurance_ Coverage_Criteria.html. Accessed on June 28, 2014.
18. American Society of Plastic and Reconstructive Surgeons (ASPS). Practice parameter for surgical treatment of skin redundancy for obese and massive weight loss patients. 2007b. Available at: http://www.plasticsurgery.org/Documents/medical-professionals/health-policy/evidence-practice/Surgical-Treatment-of-Skin-Redundancy-Following-Massive-Weight-Loss.pdf. Accessed on June 28, 2014.  
19. Buchwald H; Consensus Conference Panel. Consensus conference statement bariatric surgery for morbid obesity: health implications for patients, health professionals, and third-party payers. Surg Obes Relat Dis. 2005; 1(3):371-381.
20. Coleman WP, Glogau RG, Klein JA, et al. American Academy of Dermatology Guidelines/Outcomes Committee. Guidelines of care for liposuction. J Am Acad Dermatol. 2001; 45(3):438-447. 
21. National Institutes of Health. National Heart, Lung, and Blood Institute. BMI calculator. Available at: http://www.nhlbi.nih.gov/guidelines/obesity/BMI/bmicalc.htm. Accessed on June 28, 2014.
22. National Library of Medicine. Medical Encyclopedia: Abdominoplasty - series. Available at: http://www.nlm.nih.gov/medlineplus/ency/presentations/100184_1.htm. Accessed on June 28, 2014. 
23. National Library of Medicine. Medical Encyclopedia: Diastasis recti. Available at: http://www.nlm.nih.gov/medlineplus/ency/article/001602.htm. Accessed on June 28, 2014.

Coding Section

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross Blue Shield Association technology assessment program (TEC) and other nonaffiliated technology evaluation centers, reference to federal regulations, other plan medical policies and accredited national guidelines.

"Current Procedural Terminology © American Medical Association. All Rights Reserved" 

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