DISCLAIMER

Highmark Health Options medical policy is intended to serve only as a general reference resource regarding coverage for the services described. This policy does not constitute medical advice and is not intended to govern or otherwise influence medical decisions.

POLICY STATEMENT

Highmark Health Options may provide coverage under medical surgical benefits of the Company’s Medicaid products for medically necessary. Refer to the Noncovered Services policy for more information.

This policy is designed to address medical necessity guidelines that are appropriate for the majority of individuals with a particular disease, illness or condition. Each person’s unique clinical circumstances warrant individual consideration, based upon review of applicable medical records.

The qualifications of the policy will meet the standards of the National Committee for Quality Assurance (NCQA) and the West Virginia Department of Health and Human Resources (DHHR) and all applicable state and federal regulations.

Purpose 

This medical policy outlines Highmark Health Options services for Abdominoplasty & Panniculectomy.

Definitions

Highmark Health Options (HHO)- Managed care organization serving vulnerable populations that have complex needs and qualify for Medicaid. Highmark Health Options members include individuals and families with low income, expecting mothers, children, and people with disabilities. Members pay nothing to very little for their health coverage. Highmark Health Options currently services WV Mountain Health Trust (MHT) and West Virginia Health Bridge (WVHB) including an expansion plan (WVHB ABP Alternative Benefit Plan) and WVCHIP members.

Abdominoplasty – Abdominoplasty is typically performed for cosmetic purposes, involves the removal of excess skin and fat from the pubis to the umbilicus or above, and may include tightening of the rectus muscle and creation or transposition of the umbilicus.

Panniculectomy – A surgical procedure used to remove a panniculus, which is an apron of fat and skin that hangs from the front of the abdomen. In certain circumstances, the panniculus can be associated with skin irritation and infection due to interference with proper hygiene and constant skin-on-skin contact in the folds underneath the panniculus. The presence of a panniculus may also interfere with daily activities.

Computed tomography – Computed tomography, also referred to as “CAT scanning,” provides a different form of imaging known as cross-sectional imaging.

Panniculus – The subcutaneous fat or a layer of fat underlying the dermis (also referred to as pannus, fat apron, or abdominal apron). The layer of fat and dermis hangs from the front of the abdomen.

Lipectomy – The excision of subcutaneous adipose tissue which may be performed on various parts of the body (also referred to as belt lipectomy, liposuction, brachioplasty, buttock or thigh lift, and body lift).

Massive Weight Loss (MWL) – Loss of 50% of excess weight.

Functional Impairment – A condition that describes a state where an individual is physically limited in the performance of activities of daily living (ADL).

Intertrigo – An inflammation of the top layers of skin caused by moisture, bacteria, or fungi in the folds of the skin.

Colostomy – The surgical creation of an opening in the abdominal wall (belly). The end of the colon is brought through this opening to form a stoma. Colostomies are performed for many different diseases and problems.

Ventral hernia – A bulge or tear in the abdominal wall, resulting from weakened fascia or muscles, which allows the inner lining of the abdomen and/or intestinal loop to extend through the abdominal wall.

Incisional hernia – The most common ventral hernia. If the ventral hernia occurs along an area of a previous surgical incision, it is referred to as an incisional hernia.

“True” hernia repair – Involves opening fascia and/or dissection of a hernia sac with return of intraperitoneal contents back to the peritoneal cavity. A “true” hernia repair should not be confused with diastasis recti repair, which is the repair to the separation of the rectus abdominis muscles.

Prior Authorization

Prior Authorization may be required. Please validate codes on the Prior Authorization Lookup Tool

https://wv.highmarkhealthoptions.com/providers/prior-authorization-code-lookup.html

Procedures

Abdominoplasty and panniculectomy following massive weight loss are clinically proven and, therefore, medically necessary procedures when all of the following criteria are met (American Society of Plastic Surgeons, 2017; Mechanick, 2013):

·       A board-certified plastic surgeon performs the surgical procedure to modify the skin envelope, subcutaneous layer, and/or investing fascia

·       The patient must be 18 years of age or older; and

·       There is photographic documentation (with member standing) of at least a Grade 2
        panniculus (see Attachment) that hangs to or below the level of the pubis; and

·       Surgery will correct functional impairment caused by excessive skin and subcutaneous tissue redundancy.

·       There is photographic documentation of any of the following chronic or recurring conditions related to excess tissue and skin folds:

            o   Intertrigo (bacterial or fungal infections).

            o   Cellulitis.

            o   Folliculitis.

            o   Panniculitis.

            o   Skin ulceration.

            o   Skin or subcutaneous abscesses.

            o   Monilial infection or fungal dermatitis.

            o  Skin necrosis

Documentation of failure of at least three months of conservative non-surgical management by a physician other than the operating physician, such as:

            o   Intravenous (IV) antibiotic treatments

            o   Oral antibiotic treatments

            o   Good hygiene practices (e.g., bathing and washing daily, keeping skin dry and clean, wearing clean clothing).

            o   Wound care (occurring under or around the panniculus) including topical antifungals and topical and/or systemic corticosteroids

            o   Surgical drainage

The patient must have adequate nutrition; and

There must be MWL demonstrated by one of the following:

            o   If massive weight loss occurs as a result of bariatric surgery, the procedure should not be performed for at least 18 months after the bariatric surgery and             maintain a stable weight for a minimum of six (6) months, totaling 24 months or two (2) years.

            o   If massive weight loss occurs naturally, the patient must maintain stable weight for a minimum of 6 months after weight loss.

Panniculectomy after massive weight loss is clinically proven and, therefore, medically necessary when all of the above criteria are met.

Abdominoplasty is clinically proven and, therefore, medically necessary when performed in conjunction with a panniculectomy that meets the above criteria. In this case abdominoplasty is considered part of the panniculectomy procedure and is not separately reimbursable.

Limitations

All other indications for abdominoplasty and panniculectomy after massive weight loss are considered not medically necessary, including, but not limited to:

·       There is no history of MWL through natural occurrence or bariatric surgery.

·       Improving cosmesis in the absence of a functional impairment.

·       Relieving neck or back pain, as there is no evidence that reduction of redundant skin and tissue results in less spinal stress or improved posture or alignment. The            patient’s neck and/or back school be treated with appropriate physical therapy modalities.

·       Repairing a diastasis recti.

·       Minimizing the risk of hernia formation or recurrence.

·       Treatment of psychological or psychosocial symptoms or complaints.

Endoscopic abdominoplasty or mini-abdominoplasty is not medically necessary for any reason.

Panniculectomy when performed in conjunction with a primary abdominal surgical procedure will be considered as part of the primary surgery (e.g., incisional hernia repair) and not separately reimbursable.

·       Note: All requests for panniculectomy in conjunction with repair of an incisional, umbilical, epigastric, or ventral hernia must be documented by the patient’s medical         record and computed tomography scan recording the diameter of the fascial defect.

Panniculectomy is not covered when performed in conjunction with:

·       Abdominal or gynecologic procedures (e.g. C-section, hysterectomy, and obesity surgery).

·       Repair of abdominal wall laxity or diastasis recti to improve appearance.

·       Only improving activities of daily living without skin condition criteria for a panniculectomy.

·       Redundancies resulting from weight loss surgery when that tissue is without evidence of chronic infection or inflammation that is refractory to conservative treatment as outlined in the indications listed above

·       Improving appearance

·       Liposuction used for body contouring, weight reduction or the harvest of fat tissue for transfer to another body region for alteration of appearance of self-image or physical appearance

·       All other indications unless covered in the section above

Alternative covered services:

·       Analgesics

·       Antibiotics

·       Cortisone ointments

·       Drying agents

·       Topically applied skin barriers and supportive garments