1. Abdominoplasty, panniculectomy, and lipectomy/liposuction of the abdomen are generally considered cosmetic procedures
   
   [INFORMATIONAL NOTE: When significant weight loss is achieved such as is typically the case after bariatric procedures for morbid obesity, it is not uncommon for the patients to be left with a significant amount of redundant skin (e.g., in the abdomen, breasts, thighs and arms). Procedures to remove the redundant skin are typically considered to be cosmetic. The eligibility of procedures and/or services related to, or resulting from, a prior surgical procedure for morbid obesity is determined by the patient’s specific contract benefits.When the patient’s contract does not specifically exclude such procedures and/or services, they are subject to review for medical necessity .
   
   Medical policies pertaining to the covered person’s condition should be consulted, as applicable (e.g., Policy #025 on Abdominoplasty, Policy #028 on Reduction Mammaplasty, and Policy #001 on Cosmetic Procedures including excision of excessive skin and subcutaneous tissue and suction assisted lipectomy, under the Surgery Section). The approval of a bariatric procedure for medical necessity should not be interpreted to be an automatic approval for procedures that address the sequelae of significant weight loss, nor should it create the expectation that such procedures will be approved.
   
2. Abdominoplasty or panniculectomy may be considered reconstructive, thus medically necessary, when criteria below are met:
   1. Stability of weight for a period of 6 months post weight loss and/or bariatric surgery AND ALL OF THE FOLLOWING
      1. Panniculus at grade 2 or above, using the following scale (medical records, including photography and/or operative reports may be required to be submitted to the health plan for review):
         1. Grade 1: Panniculus covers hairline and mons pubis but not the genitals
         2. Grade 2: Panniculus covers genitals and upper thigh crease
         3. Grade 3: Panniculus covers upper thigh
         4. Grade 4: Panniculus covers mid-thigh
         5. Grade 5: Panniculus covers knees and below
      2. AND One of the following:
         1. Clinical documentation of recurrent chronic and persistent skin condition under panniculus (e.g., intertriginous dermatitis, panniculitis, cellulitis, non-healing skin ulceration, tissue necrosis, recurrent/persistent skin infection) unresponsive to 3 months of medical therapy (failed both oral and topical medications); OR
         2. Chronic maceration of overhanging skin folds that is refractory to medical therapy; OR
         3. There is a functional impairment, such as documented difficulty with ambulation due to the abdominal pannus.
            Note: Functional impairment /deficit refers to an extensive redundancy of skin and fat folds (e.g., a panniculus below the pubis). The development is often secondary to massive weight loss. An abdominal panniculus of this extent is causal to functional impairment.
            
3. Copies of original medical records must be submitted either hard copy or electronically to support medical necessity and must include:
   1. detailed history and physical examination;
   2. extent of structural impairment or functional incompetence of the anterior abdominal wall;
   3. detailed clinical history of previous and/or ongoing therapeutic interventions for the intertriginous dermatitis; and
   4. photographs of affected areas (panniculus and/or dermatitis).
4. Diastasis recti surgery in conjunction with ventral hernia repair may be medically necessary with clear documentation of
   1. ventral herniation of the abdominal viscera with risk of organ/bowel herniation with strangulation OR
   2. severe functional impairment is documented after 3-6 months of conservative therapy (physical therapy, other core strengthening activities).
      Note: Functional impairment of major life activities (ambulation, work, self-care, performance of other duties) must be documented with impart on member's ability to perform them.
5. Abdominoplasty to treat diastasis recti for any other reason is not medically necessary.

For members enrolled in Medicaid and NJ FamilyCare plans, Horizon BCBSNJ applies the above medical policy.

FIDE SNP:

For members enrolled in a Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP): (1) to the extent the service is covered under the Medicare portion of the member’s benefit package, the above Medicare Coverage statement applies; and (2) to the extent the service is not covered under the Medicare portion of the member’s benefit package, the above Medicaid Coverage statement applies.

________________________________________________________________________________________

Horizon BCBSNJ Medical Policy Development Process:

This Horizon BCBSNJ Medical Policy (the “Medical Policy”) has been developed by Horizon BCBSNJ’s Medical Policy Committee (the “Committee”) consistent with generally accepted standards of medical practice, and reflects Horizon BCBSNJ’s view of the subject health care services, supplies or procedures, and in what circumstances they are deemed to be medically necessary or experimental/ investigational in nature. This Medical Policy also considers whether and to what degree the subject health care services, supplies or procedures are clinically appropriate, in terms of type, frequency, extent, site and duration and if they are considered effective for the illnesses, injuries or diseases discussed. Where relevant, this Medical Policy considers whether the subject health care services, supplies or procedures are being requested primarily for the convenience of the covered person or the health care provider. It may also consider whether the services, supplies or procedures are more costly than an alternative service or sequence of services, supplies or procedures that are at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the relevant illness, injury or disease. In reaching its conclusion regarding what it considers to be the generally accepted standards of medical practice, the Committee reviews and considers the following: all credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, physician and health care provider specialty society recommendations, the views of physicians and health care providers practicing in relevant clinical areas (including, but not limited to, the prevailing opinion within the appropriate specialty) and any other relevant factor as determined by applicable State and Federal laws and regulations.

___________________________________________________________________________________________________________________________

Index:
Abdominoplasty, Panniculectomy and Diastasis Muscle Repair
Abdominoplasty
Diastasis Recti

References:
1. Ramirez OM. Abdominoplasty and Abdominal Wall Rehabilitation: A Comprehensive Approach. Plastic Reconstr Surg 2000 Jan;105(1):425-435.

2. Nahas FX, Augusto SM, Ghelfond C. Should Diastasis Recti Be Corrected? Aesthetic Plast Surg 1997 Jul-Aug;21(4):285-289.

3. Toranto JR. The Relief of Low Back Pain with the WARP Abdominoplasty: A Preliminary Report. Plast Recontr Surg 1990 Apr;85(4):545-555.

4. Al-Qarttan MM. Abdominoplasty in multiparous women with severe musculoaponeurotic laxity. Br J Plast Surg 1997 Sep;50(6):450-455.

5. Matarasso A, Matarasso SL. When does your liposuction patient require an abdominoplasty? Dermatol Surg 1997 Dec;23(12):1151-1160.

6. Lockwood T. Rectus muscle diastasis in males: primary indication for endoscopically assisted abdominoplasty. Plast Reconstr Surg 1998 May;101(6):1685-1691.

7. American Society of Plastic Surgeons. ASPS Recommended Insurance Coverage Criteria for Third-Party Payers. Abdominoplasty and Panniculectomy Unrelated to Obesity or Massive Weight Loss. Approved July 2006; Coding updated January 2007. (last accessed 08/26/2014)

8. American Society of Plastic Surgeons. ASPS Recommended Insurance Coverage Criteria for Third-Party Payers. Surgical Treatment of Skin Redundancy for Obese and Massive Weight Loss Patients. Approved July 2006; Coding updated January 2007. last (accessed 08/26/2014)

9. UpToDate. Overview of abdominal hernias. Literature review current through: July, 2014. Topic last updated: Oct. 9, 2012. last (accessed 08/26/2014)

10. Hurvitz KA, Olava WA, Nguyen A, Wells JH. Evidence-based medicine: Abdominoplasty. Plast Reconstr Surg. 2014 May;133()5):1214-21.

11. Sioka E, Tzovaras G, Katsogridaki G, et al. Desire for Body Contouring Surgery After Laparoscopic Sleeve Gastrectomy. Aethetic Plast Surg. 2015 Sep 22. [Epub ahead of print]

12. UpToDate. Rectus abdominis diastasis. Literature review current through September 2016. Topic last updated May 20, 2015.

13. Nahabedian M, Brooks DC. Rectus abdominis diastasis. In: UpToDate: Butler CE, Rosen M, Collins KA (Eds), UpToDate, Waltham, MA. (Accessed on October 6, 2017.)

14. Nahabedian M, Brooks DC. Rectus abdominis diastasis. In: UpToDate: Butler CE, Rosen M, Collins KA (Eds), UpToDate, Waltham, MA. (Accessed on September 7, 2018.)

15. American Society of Plastic and Reconstructive Surgeons. Recommended Insurance Coverage Criteria for Third Party Payers: Surgical Treatment of Skin Redundancy Following Massive Weight Loss. 2017. http://www.plasticsurgery.org/Medical_Professionals/Health_Policy_and_Advocacy/Health_Policy_Resources/Recommended_Insurance_Coverage_Criteria.html. Accessed August 2, 2019.

16. Millman Care Guidelines. Panniculectomy. ACG: A-0498.MCH Health. Ambulatory Care 23rd edition.Updated 2/11/2019. Accessed August 2, 2019

17. Olsson A, Kiwanuka O, Wilhelmsson S, Sandblom G, Stackelberg O. Cohort study of the effect of surgical repair of symptomatic diastsis recti abdomiis on abdominal trunk function and quality of life. BJS Open. 2019 Sep 11;3(6)”750-758. Doi: 10.4115/bjs5.50213.

18. Braga A, Caccia G, Nasi I, Ruggeri G, Di Dedda MC, Lamberti G, Salvatore S, Papadia A, Serati M. Diastasis recti abdominis after childbirth: Is it a predictor of stress urinary incontinence? J Gynecol Obstet Hum Reprod. 2019 Nov 26;101657. doi: 10.1016/j.jogoh.2019.101657.

19. Fiori F, Ferrara F, Gobatti D, Gentile D, Stella M. Surgical treatment of diastasis recti: the importance of an overall view of the problem. Hernia. 2020 Jun 20. doi: 10.1007/s10029-020-02252-0. Online ahead of print.

20. Nahabedian M, Brooks DC. Rectus abdominis diastasis. In: UpToDate: Butler CE, Rosen M, Collins KA (Eds), UpToDate, Waltham, MA. (Accessed on August 11, 2020.)

21. Brooks DC. Overview of abdominal wall hernias in adults. In: UpToDate: Rosen M, Chen W. (Eds), UpToDate, Waltham, MA. (Accessed on August 11, 2020.)


Codes:
(The list of codes is not intended to be all-inclusive and is included below for informational purposes only. Inclusion or exclusion of a procedure, diagnosis, drug or device code(s) does not constitute or imply authorization, certification, approval, offer of coverage or guarantee of payment.)

CPT*

15830
15847
17999