General Documentation Requirements for Panniculectomy, Excision of Excess Skin and Subcutaneous Tissue (Including Lipectomy) and related services:

• Stable weight loss with BMI less than 35 be obtained prior to authorization of coverage for panniculectomy surgery (when applicable);
• Description of the pannus and the underlying skin;
• Description of conservative treatment undertaken and its results;
• The medical records document(s) that the panniculus causes chronic intertrigo or candidiasis or tissue necrosis that consistently recurs over three months and is unresponsive to oral or topical medication (when applicable);
• Pre-op photograph (if requested);
• Copies of consultations (when applicable);
• Related operative report (when applicable);
• Any other pertinent information.

Coverage Criteria

• Local Coverage Determination: Plastic Surgery (L37020)
• Local Coverage Article: Billing and Coding: Plastic Surgery (A57222)

Codes

Resources

• Prior Authorization for Certain Hospital Outpatient Department (OPD) Services (CMS)
• Federal Register