Panniculectomy - JF Part B

PANNICULECTOMY, EXCISION OF EXCESS SKIN AND SUBCUTANEOUS TISSUE (INCLUDING LIPECTOMY), AND RELATED SERVICES

Abdominal lipectomy/panniculectomy is surgical removal of hanging excessive fat and skin in a transverse or vertical wedge from the abdomen but does not include muscle plication or flap elevation. This surgery is considered reconstructive when it is performed to alleviate such complicating factors as inability to walk normally, chronic pain, ulceration created by the abdominal skin fold, or intertrigo dermatitis (dermatitis occurring on opposed surfaces of the skin, skin irritation, infection, or chafing). This procedure may be done after weight loss surgery where there has been a significant of weight loss which has caused significant skin redundancy with complicating factors as indicated. Documentation should support this and preoperative photographs to support justification are recommended. Cosmetic surgery, or expenses incurred in connection with such surgery, are not covered by Medicare. Cosmetic surgery includes any surgical procedure directed at improving appearance, except when required for the prompt (i.e., as soon as medically feasible) repair of accidental injury or for the improvement of the functioning of a malformed body member.

Coverage

Effective for dates of service July 1, 2020, and after, hospital outpatient department (HOPD) providers will need to obtain prior authorization (PA) for panniculectomy, excision of excess skin and subcutaneous tissue (including lipectomy), and related services if performed in a HOPD setting and billed with the follow CPT codes.

Codes

Documentation Requirements

Documentation recommended for the support of panniculectomy, excision of excess skin and subcutaneous tissue (including lipectomy), and related services includes:

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

For PARs submitted for CPT 15877, providers should, if applicable, document the main procedure that will be performed on the same day as CPT 15877 in the documentation submitted with the PAR.

Best Practices, Documentation Feedback, Tips and Help

Abdominal lipectomy/panniculectomy is considered medically reasonable and necessary when the pannus or panniculus hangs below the level of the symphysis pubis causing one or more of the following conditions:

• Chronic intertrigo that consistently remains refractory to appropriate medical therapy (e.g., topical antifungals, corticosteroids, antibiotics) over a period of three months
• Difficulty walking or functional impairment in activities of daily living

If the procedure is being performed following significant weight loss, in addition to meeting the criteria noted above, there should be evidence that the patient has maintained a stable weight for at least six months. For patients whose weight loss is the result of bariatric surgery, abdominal lipectomy/panniculectomy should not be performed until at least 18 months after bariatric surgery and only when weight has been stable for at least the most recent six months and the BMI is less than 35.

Abdominal lipectomy/panniculectomy will be considered cosmetic (which is not a covered Medicare benefit) or not medically reasonable and necessary when performed for the reasons listed below:

• Repairing abdominal wall laxity, or diastasis recti to improve appearance
• Redundancies resulting from weight loss or 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 or self-image or physical appearance
• All other indications not listed as medically reasonable and necessary

References

• Billing and Coding Article - Plastic Surgery (A57222)
• LCD - Plastic Surgery (L37020)
• CMS Internet Only Manual (IOM), Publication 100-02, Medicare Benefit Policy Manual, Chapter 16, Sections 10 and 120
• OPD Operational Guide
• Title XVIII of the Social Security Act, Section 1862 (a)(10)