July 9, 2018 Show Asked By: Sheccid17in Illinois, IL Answer: Does Blue Cross Shield cover tummy tucks?1 person found this helpful Answer: Does Blue Cross Shield cover tummy tucks?1 person found this helpful Answer: Blue cross covering tummy tuck?Answer: Blue cross covering tummy tuck?July 13, 2018 Answer: Insurance and Tummy tucksBook a virtual consultation July 13, 2018 Answer: Insurance and Tummy tucksBook a virtual consultation July 11, 2018 Answer: It depends...Book a virtual consultation July 11, 2018 Answer: It depends...Book a virtual consultation Description: 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: 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:
Significant Weight Loss/Bariatric Surgery
Note: *Significant weight loss varies based on the member’s clinical circumstances and may be documented when the member:
Panniculectomy is considered not medically necessary unless the clinical criteria above are met. Rationale: 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: 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:
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" History From 2015 Forward
|