CG-SURG-99 Panniculectomy and Abdominoplasty

This policy addresses coverage for panniculectomy and abdominoplasty. Panniculectomy is medically necessary when the panniculus hangs below the pubis (photographic documentation) and there is either refractory (≥3 months) rash/infection/ulceration unresponsive to conventional therapy or significant interference with ambulation/ADLs, with symptoms persisting despite significant, stable weight loss (≥3 months) or failed supervised weight-loss attempts; after bariatric surgery, the individual must be ≥18 months post-op or have stable weight for ≥3 months. Not covered: panniculectomy when criteria are unmet or performed only as an adjunct to other procedures; panniculectomy/abdominoplasty for back pain; liposuction for abdominal fat removal; and abdominoplasty for skin/fat removal or muscle tightening (cosmetic).

"Panniculectomy is consideredmedically necessaryfor the individual who meets the following criteria:The panniculus hangs below the level of the pubis (which is documented in photographs);andOneof th..."