ASPS Recommended Insurance Coverage Criteria for Third-Party Payers | Surgical Treatment of Skin Redundancy for Obese and Massive Weight Loss Patients

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ASPS Recommended Insurance Coverage Criteria

for Third-Party Payers

BACKGROUND

Improvements in the surgical correction of morbid obesity via bariatric surgery as well as non-surgical diet regimens

have allowed increasing numbers of morbidly obese patients to undergo successful and sustained massive weight loss.

While the medical/health benefits of massive weight loss are obvious, it often leaves patients with unwanted skin and

fat folds that are virtually impossible to correct by diet, weight loss or exercise.

The deformities that result following massive weight loss vary greatly depending on the patient’s body type, fat

deposition patterns, and the amount of weight gained or lost. These deformities can lead to patient dissatisfaction

with appearance as well as additional health problems such as intertrigo and infections of the skin under the

overhanging panniculus of the back and abdomen, under the breasts, arms and medial thigh folds. The weight of these

skin folds can also cause or exacerbate pain in the back and shoulder girdle regions. Although the anterior abdomen is

typically the area of greatest concern and dysfunctionality, other areas such as the waist, hips, back, buttocks, breasts,

and arms are also affected following massive weight loss.

DEFINITIONS

For reference, the following definition of cosmetic and reconstructive surgery was adopted by the American Medical

Association, June 1989:

 Cosmetic surgery is performed to reshape normal structures of the body in order to improve the patient's

appearance and self-esteem.

 Reconstructive surgery is performed on abnormal structures of the body, caused by congenital defects,

developmental abnormalities, trauma, infection, tumors, or disease. It is generally performed to improve

function, but may also be done to approximate a normal appearance.

The focus of this recommended insurance coverage criteria is on the surgical treatment of the excess skin and fat that

occurs in obese patients or remains following massive weight loss. Abdominoplasty unrelated to obesity or massive

weight loss is discussed in the ASPS Recommended Insurance Coverage Criteria for Abdominoplasty and

Panniculectomy Unrelated to Obesity or Massive Weight Loss.

Excess hanging breast tissue may be treated with reduction mammaplasty which is discussed in detail in the ASPS

Practice Parameter on Reduction Mammaplasty.

Surgical Treatment of Skin Redundancy for

Obese and Massive Weight Loss Patients

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There are a wide range of defects of varying severity that may benefit from the removal of excess skin and fat. As a

result, numerous procedures and terms have developed over the years describing the techniques and special

adaptations that have been developed. Some of these terms describe similar procedures, may overlap and in some

cases be used interchangeably. To clarify the difference in the procedures, the following definitions should be utilized.

Abdominoplasty typically performed for cosmetic purposes, involves the removal of excess skin and fat from the pubis

to the umbilicus or above, and may include fascial plication of the rectus muscle diastasis and a neoumbilicoplasty.

Panniculectomy involves the removal of hanging excess skin/fat in a transverse or vertical wedge but does not include

muscle plication, neoumbilicoplasty or flap elevation. A cosmetic abdominoplasty is sometimes performed at the time

of a functional panniculectomy or delayed pending completion of weight reduction. A Panniculectomy is a non-

cosmetic procedure typically performed to assist in the correction of a functional impairment.

Circumferential Lipectomy (Belt Lipectomy, Lower Body lift) is a circumferential procedure which combines the

elements of an abdominoplasty or panniculetomy with removal of excess skin/fat from the lateral thighs and buttock.

The procedure involves removing tissue from around the circumference of the lower trunk which eliminates lower

back rolls, and provides some elevation of the outer thighs, buttocks, and mons pubis. A circumferential lipectomy

describes an abdominoplasty or panniculectomy combined with flank and back lifts, as both procedures being

performed together sequentially and including suction assisted lipectomy, where necessary. These procedures are

typically considered cosmetic.

Torsoplasty is a term which encompasses a number of operative procedures, usually done together to improve the

contour of the torso, usually female (though not exclusively). These would include abdominoplasty with liposuction of

the hips/flanks and breast augmentation and/or breast lift/reduction. In men, this could include reduction of

gynecomastia by suction assisted lipectomy/ultrasound assisted lipectomy or excision.

Medial thigh lift is a procedure that treats the excessive skin and fat of the medial thigh. Incisions in the groin or

others that extend to the knee can be required to correct the defect. Liposuction may be combined when necessary.

Only in severe cases would the case of excessive skin in the medial thigh region be considered as a functional

abnormality.

Breast reduction

is usually performed for relief symptoms such as back, neck, and shoulder pain, and skin irritation, rather

than to enhance the appearance of the breasts.

Gynecomastia

is a procedure to remove excess fat, glandular tissue and/or skin from overdeveloped or enlarged male breasts.

In severe cases of gynecomastia, the weight of excess breast tissue may cause the breasts to sag and stretch the areola. In

these cases, the position and size of the areola can be surgically improved and excess skin may need to be reduced.

POLICY

When panniculectomy is performed to eliminate a large hanging abdominal panniculus done in part to reduce

associated symptoms, cellulitis, intertrigo, shoulder pain, neck pain, back pain, thoracic spine pain, lumbago, and

panniculitis, this would be considered reconstructive.

For example, a panniculectomy to eliminate a large hanging abdominal panniculus and its associated symptoms would

be considered reconstructive. In situations where a circumferential treatment approach is utilized to also treat the

residual back and hip rolls or the ptotic buttock tissue, only the anterior portion of the procedures would be

considered reconstructive, the remaining portion of the procedure would be considered cosmetic. Only in rare

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circumstances will buttock, thigh or arm lifts be needed to treat functional abnormalities. Typically, these procedures

are performed to improve appearance and are therefore cosmetic in nature.

Patients considered for panniculectomy may be required to/ should document the type and duration of symptoms/

treatment for panniculitis. Documented recalcitrant panniculitis may be considered as indication for panniculectomy.

Photographs should confirm the patients’ medical condition.

Patients considered for panniculectomy may be required to/ should document specialist (back) evaluation, radiological

evaluation and duration of symptoms/ treatment for chronic back pain felt related to their panniculus. Direct

correlation is recommended before panniculectomy is considered. Photographs should confirm the patients’ medical

condition. Improvement in a patient’s activities of daily living should not be considered as an indication for

panniculectomy.

CODING

The following codes are provided as a guideline for the physician and are not meant to be exclusive of other possible

codes. Other codes may be acceptable depending on the nature of any given procedure.

Diagnosis ICD-10 Code

Cosmetic Procedures

Plastic surgery for unacceptable

cosmetic appearance Z41.1

Functional Diagnosis Codes

Localized adiposity – fat pad E65

Lymphedema I89.0

Hypertrophy of breast N62

Cellulitis – trunk L03.319

Cellulitis of axilla &upper arm L03.111 – L03.114

Cellulitis of lower limb L03.115, L03.116

Intertrigo L26, L30.4, L53.8

Shoulder pain M25.511 – M25.519

Neck pain M54.2

Pain in thoracic spine M54.6

Lumbago M54.5

Diastasis recti M62.00, M62.08

Panniculitis M79.3

Procedure

CPT Code

Panniculectomy (Functional or Cosmetic)

Excision, excessive skin and subcutaneous tissue

(includes lipectomy); abdomen, infraumbilical panniculectomy

15830

Abdominoplasty (Cosmetic)

Excision, excessive skin and subcutaneous tissue (includes lipectomy), abdomen (eg,

abdominoplasty)

(includes umbilical transposition and fascial plication)

List separately in addition to code for primary procedure

+ 15847

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Use 15847 in conjunction with 15830

For abdominal wall hernia repair, see 49491-49587

To report other abdominoplasty, use 17999

Excision, excessive skin and subcutaneous tissue (includes lipectomy); thigh

15832

Excision, excessive skin and subcutaneous tissue (includes lipectomy); leg

15833

Excision, excessive skin and subcutaneous tissue (includes lipectomy); hip

15834

Excision, excessive skin and subcutaneous tissue (includes lipectomy); buttock

15835

Excision, excessive skin and subcutaneous tissue (includes lipectomy); arm

15836

Excision, excessive skin and subcutaneous tissue (includes lipectomy); forearm or hand

15837

Excision, excessive skin and subcutaneous tissue (includes lipectomy); Submental fat pad

15838

Excision, excessive skin and subcutaneous tissue (includes lipectomy); other area

15839

Mastectomy for gynecomastia

19300

Mastopexy

19316

Reduction mammaplasty

19318

CODING HERNIA REPAIRS

In rare circumstances plastic surgeons may perform a hernia repair in conjunction with an abdominoplasty or

panniculectomy. A 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 part of a standard abdominoplasty. When a true hernia repair is performed, the following codes may

be utilized.

Diagnosis Codes ICD-10 Code

Umbilical hernia K42.9

Ventral, unspecified K43.9

Incisional K43.2

Procedure

CPT Code

Repair initial incisional or ventral hernia; reducible

49560

Repair initial incisional or ventral hernia; incarcerated or strangulated

49561

Repair recurrent incisional or ventral hernia; reducible

49565

Repair recurrent incisional or ventral hernia; incarcerated or strangulated

49566

Implantation of mesh or other prosthesis for incisional or ventral hernia repair

(List separately in addition to code for the incisional or ventral hernia repair)

+ 49568

Repair epigastric hernia (eg, preperitoneal fat); reducible

49570

Repair epigastric hernia (eg, preperitoneal fat); incarcerated or strangulated

49572

Repair umbilical hernia, age 5 or over; reducible

49585

Repair umbilical hernia, age 5 or over; incarcerated or strangulated

49587

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PRIMARY REFERENCE

American Society of Plastic Surgeons. Practice Parameter for Surgical Treatment of Skin Redundancy for Obese and

Massive Weight Loss Patients. Date: December 2016.

ADDITIONAL REFERENCES

1. Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults –

executive summary. http://www.nhlbi.nih.gov/files/docs/guidelines/ob_gdlns.pdf Accessed: 11/14/2016

2. Managing Overweight and Obesity in Adults: Systematic Evidence Review from the Obesity Panel-

http://www.nhlbi.nih.gov/sites/www.nhlbi.nih.gov/files/obesity-evidence-review.pdf Accessed: 11/14/2016

3. Overweight and obesity. http://www.cdc.gov/obesity/adult/index.html Accessed 11/14/2016.

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for body contour surgery. Clin. Plast. Surg. 31:601, 2004.

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May;137(5):1434-46.

7. Staalesen T, Olsén MF, Elander A. The Effect of Abdominoplasty and Outcome of Rectus Fascia Plication on

Health-Related Quality of Life in Post-Bariatric Surgery Patients. Plast Reconstr Surg. 2015 Dec;136(6):750e-61e.

8. Aly, A.S., Cram, A.E., Heddens, C. Truncal body contouring surgery in the massive weight loss patient. Clin.

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12. Abramson, D.L. Minibrachioplasty: minimizing scars while maximizing results. Plast Reconstr. Surg. 114:1631,

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13. Grieco M, Grignaffini E, Simonaccai F, Di Mascio D, Raposio E. Post-bariatric body contouring: our

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444 East Algonquin Road • Arlington Heights, IL 60005-4664 • 847-228-9900 •

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16. Coriddi, M. et al. Changes in Quality of Life and Functional Status following Abdominal Contouring in the

Massive Weight Loss Population. PRS journal, vol. 128, number 2, 520-526 (2011).

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(2):245-55.

18. Coriddi, M. et al. Reduction mammoplasty, obesity, and massive weight loss: temporal relationships of

satisfaction with breast contour. Plast Reconstr Surg. 2011 Sept; 128(3):643-50.

Approved by the ASPS® Executive Committee: June 2017