Download National Medical Policy

National Medical Policy
Subject:
Abdominoplasty/Panniculectomy/SuctionAssisted Lipectomy/Ventral Hernia Repair
Policy Number:
NMP149
Effective Date*:
May 2004
Updated:
November 2015
This National Medical Policy is subject to the terms in the
IMPORTANT NOTICE
at the end of this document
For Medicaid Plans: Please refer to the appropriate State’s Medicaid
manual(s), publication(s), citation(s), and documented guidance for
coverage criteria and benefit guidelines prior to applying Health Net
Medical Policies
The Centers for Medicare & Medicaid Services (CMS)
For Medicare Advantage members please refer to the following for coverage
guidelines first:
Use
X
X
Source
National Coverage Determination
(NCD)
National Coverage Manual Citation
Local Coverage Determination
(LCD)*
Reference/Website Link
Article (Local)*
Cosmetic vs. Reconstructive Surgery Coverage:
http://www.cms.gov/medicare-coveragedatabase/search/advanced-search.aspx
Other
None
Plastic Surgery:
Cosmetic and Reconstructive Surgery:
http://www.cms.gov/medicare-coveragedatabase/search/advanced-search.aspx
Use Health Net Policy
Instructions
 Medicare NCDs and National Coverage Manuals apply to ALL Medicare members
in ALL regions.
 Medicare LCDs and Articles apply to members in specific regions. To access your
specific region, select the link provided under “Reference/Website” and follow the
search instructions. Enter the topic and your specific state to find the coverage
determinations for your region. *Note: Health Net must follow local coverage
determinations (LCDs) of Medicare Administration Contractors (MACs) located
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

outside their service area when those MACs have exclusive coverage of an item
or service. (CMS Manual Chapter 4 Section 90.2)
If more than one source is checked, you need to access all sources as, on
occasion, an LCD or article contains additional coverage information than
contained in the NCD or National Coverage Manual.
If there is no NCD, National Coverage Manual or region specific LCD/Article,
follow the Health Net Hierarchy of Medical Resources for guidance.
Health Net, Inc. considers an initial abdominoplasty / panniculectomy / suctionassisted lipectomy medically necessary or medically unnecessary according to the
following:
Panniculectomy
Health Net Inc. considers panniculectomy, with or without abdominoplasty and/or
suction-assisted lipectomy, medically necessary for the following:
Patients who have undergone substantial weight loss (e.g., bariatric surgery)
resulting in an overhanging “apron” of redundant skin and fat (panniculus) in the
lower abdominal area when all of the following clinical criteria are met:

The patient’s weight has remained stable for a period in excess of six months
following a massive weight loss or if the weight loss is the result of bariatric
surgery, abdominoplasty/panniculectomy should not be performed until at
least 12-18 months following bariatric surgery and weight has been stable for
at least the most recent six months

Panniculus hangs to or below the level of the pubis as documented by
photographs*; and

There is photographic* evidence of any of the following chronic or recurring
conditions refractory to appropriate medical therapy (e.g., analgesics,
antibacterials, antifungals, cortisone ointments, drying agents, strict attention
to hygiene, topically applied skin barriers and supportive garments) for a
period of at least 6 months as documented in serial office notes:
 Intertrigo (bacterial or fungal infections)
 Cellulitis
 Folliculitis
 Panniculitis
 Skin ulceration
 Skin/subcutaneous abscesses not responsive to conventional
medical therapy including a trial of oral antibiotics and topical
therapies
 Monilial infestation / fungal dermatitis
 Actual skin necrosis
*Note: Preoperative photographs, chin to waist, standing frontal and lateral with
hands at sides, and one with the abdominal fold raised to document any reported
skin changes are an absolute requirement for determination of medical
appropriateness.
Note: Abdominal panniculectomy performed in conjunction with a primary abdominal
surgical procedure will be considered as part of the primary surgery (e.g., incisional
hernia repair).
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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 CT scan recording the diameter of the fascial defect.
Abdominoplasty
Health Net, Inc considers abdominoplasty medically necessary according to the
following criteria:
1. It is medically necessary only when it is performed in conjunction with a
panniculectomy that meets the above criteria; however, as its primary purpose
is to reduce the appearance of a protruding abdomen secondary to a diastasis
recti, which is not a true hernia and is of no clinical significance,
abdominoplasty is considered as part of the panniculectomy and is not a
separate procedure
2. It is not medically necessary when performed as the primary procedure, with
or without suction-assisted lipectomy, to enhance the patient's appearance, as
this is considered cosmetic in nature
Note: Endoscopic abdominoplasty or mini-abdominoplasty is not considered
medically necessary for any reason.
Suction-Assisted Lipectomy
Health Net, Inc considers suction-assisted lipectomy (liposuction) medically
necessary according to the following criteria:
1. It is medically necessary only when it is performed in conjunction with a
panniculectomy that meets the above criteria; however, when its primary
purpose is to enhance the patient's appearance, suction-assisted lipectomy is
considered cosmetic in nature
2. It is not medically necessary when it is performed as the primary procedure
solely to enhance the patient's appearance, as this is considered cosmetic in
nature
3. A belt lipectomy, which combines an abdominoplasty with the circumferential
excision of skin and fat for patients with circumferential trunk excess, is not
medically necessary and, therefore, ineligible for coverage.
Note: Health Net, Inc does not consider suction assisted lipoma extraction medically
necessary because it has no literature to support it as standard of care. This
procedure does not remove the capsule, thus allowing for recurrence. Small lipomas,
which make up the vast majority of these benign tumors, are much more readily and
easily removed by cold knife excision and "expulsion". Health Net Inc may allow for
suction assisted lipoma removal for an exceptional case of a massive tumor or for
biopsy in consideration of liposarcoma.
Hernia Repair
Health Net, Inc considers hernia repair medically necessary when the diameter of the
fascial defect of an incisional, umbilical, epigastric or ventral hernia is substantiated
by the patient’s medical record
Note: According to the medical literature, the condition of diastasis recti presents as
a weakness or laxity of the anterior abdominal wall; as such, it does not constitute a
“true” hernia; it is not reducible, does not require surgical intervention, and is
harmless and clinically insignificant. If it is unclear as whether or not the patient has
a “true” ventral hernia or a diastasis recti, it is reasonable to ask the provider to
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obtain a CT scan, which should demonstrate the defect in the anterior abdominal
wall.
Health Net, Inc. considers the use of FlexHD Acellular Dermis for hernia repair as
investigational. Although there are ongoing studies, there continues to be insufficient
evidence on the efficacy and safety of FlexHD for hernia repair.
Specifically, Health Net, Inc does not consider abdominoplasty/ panniculectomy/
suction-assisted lipectomy medically necessary for any of the following:

The procedure(s) is performed solely to enhance the patient's appearance, as
this is considered cosmetic in nature

Permanent overstretching, with or without diastasis recti, of the anterior
abdominal wall secondary to massive weight loss or pregnancy resulting in a
large pendulous or protruding abdomen without evidence of signs and/or
symptoms of clinical or functional abnormalities documented by the patient’s
medical record or by photographs; or

Suction-assisted lipectomy (liposuction) as a primary procedure because it is
considered cosmetic

Abdominoplasty performed by liposuction only for localized areas of fat
deposits

Panniculectomy / liposuction performed in the arms and/or legs (e.g.,
brachioplasty)

Correction of low back pain because in most individuals this condition is multifactorial and the primary cause may not be the abdominal panniculus; or

Poorly fitting clothes; or

Problems with hygiene; or

Difficulty exercising

Breathing difficulties

Trouble bending to put on socks and shoes, and to wash lower extremities

Walking, sitting or even eating meals at a table

Stretch marks that sometimes open and bleed

Patient no longer able to work.
Codes Related To This Policy
NOTE:
The codes listed in this policy are for reference purposes only. Listing of a code in
this policy does not imply that the service described by this code is a covered or noncovered health service. Coverage is determined by the benefit documents and
medical necessity criteria. This list of codes may not be all inclusive.
On October 1, 2015, the ICD-9 code sets used to report medical diagnoses and
inpatient procedures have been replaced by ICD-10 code sets.
ICD-9 Codes
112.89
112.9
553.1
Other candidiasis of other specified sites
Candidiasis of unspecified site
Umbilical hernia
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553.2
553.21
553.29
682.2
695.89
701.8
729.39
Ventral hernia
Incisional hernia
Epigastric hernia
Cellulitis, trunk
Intertrigo
Other specified hypertrophic and atrophic conditions of the skin
Panniculitis
ICD-10 Codes
B37.89
B37.9
K42.0K42.9
K43.0K43.9
K46.9
L03.319
L03.329
L30.4
L57.4
L66.4
L90.4
L90.8
L91.8
M79.3
Other sites of candidiasis
Candidiasis, unspecified
Umbilical hernia
Ventral hernia
Unspecified abdominal hernia without obstruction or gangrene
Cellulitis of trunk, unspecified
Acute lymphangitis of trunk, unspecified
Erythema intertrigo
Cutis laxa senilis
Folliculitis ulerythematosa reticulata
Acrodermatitis chronica atrophicans
Other atrophic disorders of skin
Other hypertrophic disorders of the skin
Panniculitis, unspecified
CPT Codes
15830
15847
49560
49561
49585
49587
Excision, excessive skin and subcutaneous tissue (includes lipectomy);
abdomen, infraumbilical panniculectomy
Excision, excessive skin and subcutaneous tissue (includes lipectomy),
abdomen (e.g. abdominoplasty) (includes umbilical transposition and
fascial placation)
Repair initial incisional or ventral hernia; reducible
Repair initial incisional or ventral hernia; incarcerated or strangulated
Repair umbilical hernia, age 5 or older; reducible
Repair umbilical hernia, age 5 or older; incarcerated or strangulated
CPT Codes NOT Considered Medically Necessary
15832
15833
15834
15835
15836
15837
15838
15839
15876
15879
Excision, excessive skin and subcutaneous tissue,
thigh
Excision, excessive skin and subcutaneous tissue,
Excision, excessive skin and subcutaneous tissue,
Excision, excessive skin and subcutaneous tissue,
buttock
Excision, excessive skin and subcutaneous tissue,
arm
Excision, excessive skin and subcutaneous tissue,
forearm or hand
Excision, excessive skin and subcutaneous tissue,
submental fat pad
Excision, excessive skin and subcutaneous tissue,
other area
Suction assisted lipectomy; trunk
Suction assisted lipectomy; head and neck
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including lipectomy;
including lipectomy; leg
including lipectomy, hip
including lipectomy;
including lipectomy;
including lipectomy;
including lipectomy;
including lipectomy;
5
HCPCS Codes
N/A
Scientific Rationale – Update October 2013
Bochicchio et al (2013) compared 2 different acellular dermal matrices in regard to
hernia recurrence and complications in patients who present with a large complicated
ventral hernia as a result of trauma or emergency surgery. This prospective quasiexperimental time-interrupted series design evaluated the incidence of hernia
recurrence in trauma/emergency surgery patients who had a ventral hernia repair
with a biologic matrix. From January 2005 to December 2007, 55 patients with a
complicated ventral hernia were repaired with AlloDerm (Life Cell Corporation).
Beginning in February 2008 to January 2010, 40 patients with the same criteria were
repaired with FlexHD (Musculoskeletal Transplant Foundation) and followed
prospectively over the following year. The primary outcome for this study was hernia
recurrence (functional or real) at 1 year. Other outcomes variables included
abdominal laxity, seroma formation, and wound or intra-abdominal infection.
There was no significant difference in age, sex, and body mass index between the
groups. In addition, there was no significant difference in the mean hernia size and
size of the acellular dermis that was inserted. At 1 year postsurgery, all of the
AlloDerm patients were diagnosed with recurrence requiring a second formal repair.
Eleven patients (31%) whose hernias were repaired with FlexHD were diagnosed
with a recurrence requiring a second formal repair. Authors concluded FlexHD
appears to have reduced the recurrence and laxity rates while maintaining a similar
complication profile compared with AlloDerm in trauma/emergency surgery patients
with large complicated ventral hernias.
Scientific Rationale – Update October 2012
Janfaza et al. (2012) completed a retrospective, single-center, comparative study,
and evaluated the efficacy and safety of hernia repair with FlexHD or SurgiMend
(n=35) in 25 general surgery patients and 10 trauma patients with complex
abdominal wall hernias who were at high risk for complications due to wound
contamination or comorbidities. Indications for hernia repair were open abdomen in
trauma patients, and intestinal obstruction, colon perforation, and hernia recurrence
in general surgery patients. FlexHD was used in 12 patients (mean age 49 years)
and SurgiMend was used in 23 patients (mean age 45 years) to repair 34 ventral
hernias and 1 flank hernia. Study outcomes included surgical site infections, hernia
recurrences, hospital length of stay, and mortality. The biologic mesh was used to
bridge the gap of the hernia defect through direct attachment to the fascia or
placement in a subfascial plane. Both the hernia dimensions based on transverse
diameter and the rates of recurrent hernias were similar in the two groups. Both
groups had high rates of contaminated wounds (~ 50%). Patients were followed for
1 year. Compared with the SurgiMend group there were more surgical site infections
(50% versus 17%, P=0.03), superficial infections (25% versus 5%, P=0.02), and
hernia recurrences (33% versus 5%, P=0.04) in the FlexHD group. Rates of deep
infections with mesh involvement were similar between groups (13% and 17%,
P=1.0). The incidence of hernia recurrence due to infection was higher in the FlexHD
group (50% versus 5%) although the statistical significance was not reported. No
patients died. The mean hospital length of stay was similar in the FlexHD (13 days)
and SurgiMend (10 days) groups (P=0.50). These data suggest that short-term
outcomes, particularly hernia recurrence, were more favorable for hernias treated
with SurgiMend than for those treated with FlexHD. This study is limited by
weaknesses in its design and inadequate follow-up time. NOTE: The authors had no
conflicts of interest.
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There is currently a Clinical Trial recruiting participants on ‘Comparative Effectiveness
Multicenter Trial for Adhesion Characteristics of Ventral Hernia Repair Mesh’,
ClinicalTrials.gov Identifier number is NCT01355939. The proposed study will
compare the benefits, harms, and comparative effectiveness of intraperitoneal
barrier-coated and non-barrier coated ventral hernia repair (VHR) mesh in reducing
adhesions, adhesion-related complications, and adhesiolysis sequelae in actual
patient subpopulations and clinical circumstances. A subset of the data will be
analyzed to compare the benefits, harms, and comparative effectiveness of the
laparoscopic and open approaches to adhesiolysis. A comprehensive array of healthrelated risk factors and patient-centered outcomes will be assessed in the
investigators diverse patient population for proper multivariate data analysis.
FLEXHD is one of the assigned interventions to be used. The study was last updated
on October 31, 2011.
International Hernia Mesh Registry (IHMR): This prospective, multicenter,
observational registry began enrollment in September 2007 with an estimated
minimum enrollment of 3500 patients who received a surgically implanted mesh
product (synthetic or biologic) for repair of a hernia defect. The primary outcome
measures are patient-reported hernia recurrence rates and pain assessment scores
for the 5-year duration of the registry. The registry is sponsored by Ethicon Inc. and
the estimated completion date is December 2015.
In 2010, the Canadian Agency for Drugs and Technologies for Health (CADTH)
presented a rapid report on the clinical indications, clinical effectiveness, costeffectiveness, and clinical practice guidelines of biologic meshes used as surgical
reconstructive materials. They performed a limited literature search applying filters
to limit the retrieval to health technology assessments, systematic reviews, metaanalyses, randomized controlled trials, nonrandomized studies, economic studies,
and guidelines. Studies were considered for inclusion if they assessed the clinical
effectiveness of any biologic mesh material used in a surgical procedure involving
humans. The report identified evidence concerning the use of biologic mesh for a
wide range of surgical procedures, including inguinal hernia repair as well as other
procedures. There was insufficient clinical evidence to assess the comparative
efficacy of biologic and synthetic mesh products. The report identified an abundance
of varied mesh products available, and an absence of evidence regarding differences
in safety and efficacy. The report concluded that there is currently insufficient
evidence to clearly establish the place in therapy of biologic mesh products, (i.e.,
FLEXHD Acellular Dermis).
In summary, the available evidence on the efficacy and safety of FlexHD for hernia
repair is extremely limited. Factors to consider in relation to complications following
hernia repair are infection risk, adhesion risk, recurrence, mesh degradation, serosa,
and pain. Firm conclusions on the safety and efficacy of this allograft await
evaluation of evidence from ongoing studies that are now in progress. Comparative
peer-reviewed studies are needed to determine the potential advantages and relative
efficacy and safety of FlexHD versus other biologic or synthetic meshes.
Scientific Rationale – Update December 2010
According to the American Society of Plastic Surgeons, surgery to remove extensive
skin redundancy and fat folds performed solely to enhance a patient's appearance in
the absence of any signs or symptoms of functional abnormalities, should be
considered cosmetic in nature. In some instances, however, California law requires
coverage of surgery to restore normal appearance (please refer to page 12 of the
policy for details). An abdominoplasty or panniculectomy may be utilized to treat a
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wide range of abdominal defects, from purely cosmetic indications to conditions such
as the treatment of excess skin following massive weight loss.
According to a Practice Parameter from the American Society of Plastic Surgeons,
body contouring surgery is ideally performed after the patient maintains a stable
weight for two to six months. For post bariatric surgery patients, body contouring
surgery is ideally performed 12-18 months after bariatric surgery or at the 25
kg/mg2 to 30 kg/mg2 weight range.
Ortega et al (2010) aimed to quantify the need for panniculectomy after open
bariatric surgery and to analyze the postoperative outcomes in a retrospective cohort
study. Patients were divided into 2 groups: group DLP, patients who underwent an
abdominal panniculectomy alone and group DLP+, those who underwent
panniculectomy in association with another surgical procedure. Four hundred fortysix patients underwent open bariatric surgery and 130 patients (29%) subsequently
required an abdominal dermolipectomy. Seventy-six percent presented also
incisional hernia and 8% presented cholelithiasis. Forty-six percent of patients
presented postoperative complications: wound seroma/infection (21%), wound
dehiscence due to skin necrosis (13%), and hemorrhage/hematoma (10%) were the
most frequent. There were no major complications or mortality. DLP+ was not
associated with an increase in complications. The authors concluded after open
bariatric surgery, an abdominal panniculectomy is often required. The procedure has
a high postoperative morbidity in these patients, although complications are usually
mild. There is not an increase in the rate of complications when panniculectomy is
associated with other procedures.
Arthurs et al (2007) performed a a retrospective cohort study set in a tertiary care
center, evaluating 126 post-bariatric panniculectomies performed over a 3-year
period. Perioperative and postoperative data were collected through chart review.
Descriptive and inferential analyses were performed using SPSS 11.0. Ninety-six
percent of patients were female. Mean age of the population was 42 (+/-12). The
average post-bariatric weight loss and pre-panniculectomy weight were 53 (+/-16)
kg and 78 (+/-14) kg, respectively. Complication rates were as follows: seroma
17%, hematoma 13%, surgical site infection (SSI) 17%, transfusion 6%, skin
breakdown/necrosis 11%, and re-exploration 11%. Forty percent of patients
experienced a complication. Using multivariate logistic regression, the investigators
evaluated age, pre-panniculectomy body mass index (BMI), American Society of
Anesthesiologists (ASA) class, specimen weight, and operative duration; only prepanniculectomy BMI was an independent predictor for developing a postoperative
complication (odds ratio 3.3, confidence interval 1.2 to 8.4, P < .01). The
investigators concluded post-bariatric patients who have sustained significant weight
loss report subjective improvement after panniculectomy. Even though this
population has experienced significant weight loss, they are still at an increased risk
for postoperative complications. Maximal reduction in BMI should be stressed to
these patients in order to reduce their risk of complications following
panniculectomy.
Scientific Rationale
According to the American Society of Plastic Surgeons: “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.”
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The panniculus adiposus is a layer of tissue bearing deposits of fat underneath the
skin. After significant weight loss in men or women, particularly those with morbid
obesity, an overhanging "apron" of redundant skin and fat may develop in the lower
abdominal area. Created by the lack of underlying supportive tissue, these redundant
skin folds do not respond to weight loss methods or exercise. Panniculectomy may
be performed when permanent overstretching of the upper abdominal wall occurs.
Panniculectomy is a surgical procedure in which this large, redundant apron of
subcutaneous fat and abdominal skin is removed from the lower abdomen. Under
most circumstances, panniculectomy is a cosmetic service. However, skin chaffing
may be present under the folds sometimes extending down to or below the level of
the pubis, which may create an environment favorable to recurrent or non-healing
areas of intertrigo (bacterial or fungal infections), which may or may not respond to
appropriate therapies. In patients with stable weight who do not respond to
conventional medical therapies after a reasonable period of time, it may be
necessary to perform a panniculectomy for medical reasons. Moreover, in patients
with significant functional impairment, such as considerable difficulty with walking,
Panniculectomy may be indicated. Sometimes abdominoplasty is performed
concurrently with panniculectomy in order to achieve the best cosmetic result.
The main musculature of the abdomen is held together at the anterior midline by a
long, triangular structure called the linea alba whose insertion is at the xiphoid
process of the sternum, and which extends downward to the pubis. According to the
medical literature, the presence of diastasis recti does not automatically imply the
presence of a ventral hernia. Abdominoplasty is the surgical procedure which
involves tightening of a lax anterior abdominal wall by plication of the anterior rectus
sheath and removal and sculpting of the abdominal flap by removal of excess
subcutaneous fat and abdominal skin (also referred to as a “Tummy Tuck”). This
procedure reduces the appearance of a protruding abdomen, giving a flatter, firmer,
tighter stomach and thin waist and provides an overall improvement in the person’s
shape and figure. Men and women who continue to have fat deposits and loose
abdominal skin that won’t respond to diet and/or exercise or women with slack
muscles and skin due to multiple pregnancies or large babies are the usual
candidates for this procedure. As such, an abdominoplasty per say is performed
solely to enhance a patient's appearance in the absence of any signs or symptoms of
functional abnormalities; in other words, this procedure is considered cosmetic in
nature.
Abdominoplasty can be performed by liposuction only (for localized areas of fat
deposit), partial abdominoplasty/ Mini “Tummy Tuck” (incision in lower
abdomen/pubis only) or complete abdominoplasty/ Full “Tummy Tuck” (incision in
lower abdomen/pubis and around the umbilicus). Liposuction may also be
performed in conjunction with a “Tummy Tuck” to further sculpt the abdomen or
remove fat from other areas such as the hip. Belt lipectomy, a procedure that
combines abdominoplasty with circumferential excision of skin and fat, is
often more ideal for patients with circumferential truncal excess. Belt lipectomy
improves abdominal contour, abdominal wall laxity, mons pubis ptosis, back rolls,
waist contour, and buttocks contour. Initially, the procedure was performed on postweight-reduction patients only, but its indications were extended to three
other groups: (1) patients who were 30 to 50 pounds overweight; (2) patients of
normal weight who desired a significant overall truncal improvement; and (3) an
obese patient with persistent intra-abdominal excess.
Suction-assisted lipectomy, or liposuction, is defined as the surgical excision of fatty
tissues by means of aspiration cannulas, introduced through small skin incisions,
assisted by suction. Tumescent liposuction refers to the refinement of the procedure
that involves subcutaneous infiltration of high volumes of crystalloid fluid containing
Abdominoplasty Nov 15
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low concentrations of lidocaine and epinephrine followed by suction-assisted
aspiration of fat, by using small aspiration cannulas. The term tumescent liposuction
specifically excludes the use of any additional anesthesia medications at dosages that
have a significant risk for impairing the protective airway reflexes or for suppressing
the respiratory drive. It is a method for performing liposuction surgery with the
patient under local anesthesia.
Liposuction abdominoplasty, liposuction of abdominal subcutaneous tissue deep and
superficial to Scarpa's fascia, with excision of excess abdominal skin and, when
indicated, plication of the anterior rectus sheath without undermining, is an effective,
low-risk approach to minimizing abdominal flap undermining. The technique allows
aggressive thinning and "sculpting" of full-thickness abdominal subcutaneous tissue
and achieves a natural abdominal contour. It minimizes the creation of "dead space,"
which often leads to postoperative complications, as well as preserves sensory nerve
and blood supply to the abdominal skin. The operation may be performed with the
patient under local anesthesia, which probably diminishes the risk for deep vein
thrombosis. Moreover, additional procedures can be conducted safely and the
postoperative course is short, uneventful, and without restrictions; patients return to
normal activity within a week or so. Body contouring technically involves removal of
fat, skin, or both. In general, removal of fat only can be performed with fewer scars
and a faster recovery. It is usually performed in the younger patient, where the skin
is elastic enough to drape normally after removal of even a large amount of fat. In
the older patient and after massive weight loss and pregnancy, it is more common
that a skin excision needs to be performed in conjunction with the removal of fat.
Ventral (incisional) hernias usually occur as a result of inadequate healing of a
previous incision or excessive strain at the site of an abdominal wall scar. These
hernias can be particularly bothersome due to their high recurrence and complication
rates. Many of the factors that lead to the development of incisional hernias persist
at the time of a second repair. Some of these factors can be altered during a phase
of preoperative preparation, whereas others are lifelong or progressively worsening
conditions.
Obesity is one of the leading causes of the development of incisional hernias. The
bulk associated with a fatty omentum and excessive subcutaneous tissue provides
increased strain on the operative wound during early healing. Many of these
individuals have an associated loss of muscle mass and tone and therefore possess
inadequate strength at the fascial level to compensate for the added strain. An
attempt at weight reduction is often recommended before the repair of an incisional
hernia, but few patients actually comply with this recommendation to a degree that
lowers the risks associated with reoperation. Surgical repair in an obese patient is
associated with an increased potential for pulmonary complications, wound infection,
pulmonary embolus, and hernia recurrence.
The condition of diastasis recti presents as a weakness or laxity of the abdominal
wall separating the two rectus muscles along the median line of the abdominal wall.
This does not constitute a “true” hernia; it is not reducible, does not have defined
edges, does not require surgical intervention, and is harmless and clinically
insignificant. In order to distinguish a ventral hernia repair from a purely cosmetic
abdominoplasty, the size of the hernia, whether the ventral hernia is reducible,
whether the hernia is accompanied by pain or other symptoms, whether there is a
defect (as opposed to mere thinning) of the abdominal fascia all come into
consideration.
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Review History
May 11, 2004
May 2006
July 2006
March 2007
August 2008
October 2009
December 2010
September 2011
August 2012
October 2012
October 2013
October 2014
November 2015
Medical Advisory Council
Update – no revisions
Update – revised to require CT scan only to substantiate
ventral hernia when diastasis recti suspected
Code updates
CA reconstructive surgery law added to Disclaimer
Added ‘as documented in the serial notes’ to the verbiage,
“There is photographic evidence of any of the following
chronic or recurring conditions refractory to appropriate
medical therapy”
Under medical necessity criteria for panniculectomy,
removed requirement in first bullet, “Documented weight
loss greater than 100 lbs”. Revised second bullet to state,
“If the weight loss is the result of bariatric surgery,
abdominoplasty/panniculectomy should not be performed
until at least 12-18 months following bariatric surgery and
weight has been stable for at least the most recent six
months.” Code updates. Added Medicare table and link to
Medicare LCD regarding Plastic Surgery
Update – no revisions
Update – no revisions
Update – Added FLEXHD Acellular Dermis as investigational
for Hernia Repair
Update – no revisions. Code updates
Update – no revisions. Code updates
Update – no revisions. Code updates
This policy is based on the following evidence-based guidelines:
1. American Society of Plastic and Reconstructive Surgeons. Position Paper:
Abdominoplasty June 1994.
2. American Society of Plastic and Reconstructive Surgeons. Position Paper:
Treatment of Skin Redundancy Following Massive Weight Loss June, 1996.
3. American Society of Plastic and Reconstructive Surgeons. Practice Parameter for
Surgical Treatment of Skin Redundancy Following Massive Weight Loss. January
2007.
4. Hayes. Health Technology Brief. Panniculectomy for Abdominal Contouring
Following Massive Weight Loss. September 19, 2012. Updated August 26, 2014.
Archived October 9, 2015.
References – Update November 2015
1.
2.
3.
Hurvitz KA, Olaya WA, Nguyen A, Wells JH. Evidence-based medicine:
Abdominoplasty. Plast Reconstr Surg. 2014;133(5):1214-1221.
Fisher KA, Olaya WA, Nguyen A, Wells JH. Evidence-based medicine:
Abdominoplasty. Plast Reconstr Surg. 2014;133(5):1214-1221.
Koolen PG, Ibrahim AM, Kim K, et al. Patient selection optimization following
combined abdominal procedures: Analysis of 4925 patients undergoing
panniculectomy/abdominoplasty with or without concurrent hernia repair. Plast
Reconstr Surg. 2014;134(4):539e-550e.
References – Update October 2014
1.
Aboelatta YA, Abdelaal MM, Bersy NA. The effectiveness and safety of combining
laser-assisted liposuction and abdominoplasty. Aesthetic Plast Surg.
2014;38(1):49-56.
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2.
3.
4.
5.
6.
Bogdanov-Berezovsky A Acute esophageal dilation mimicking serious pulmonary
complication after post-bariatric abdominoplasty. Aesthetic Plast Surg. 01-FEB2013; 37(1): 171-2.
Constantine RS, Davis KE, Kentel JM. Aesthet Surg J. 2014 May 1;34(4):578-83.
doi: 10.1177/1090820X14528208. Epub 2014 Mar 27.The effect of massive
weight loss status, amount of weight loss, and method of weight loss on body
contouring outcomes.
Danilla S, Longton C, Valenzuela K, et al. Suction-assisted lipectomy fails to
improve cardiovascular metabolic markers of disease: A meta-analysis. J Plast
Reconstr Aesthet Surg. 2013;66(11):1557-1563.
Levesque AY, Daniels MA, Polynice A. Outpatient lipoabdominoplasty: Review of
the literature and practical considerations for safe practice. Aesthet Surg J.
2013;33(7):1021-1029.
Sodkin M, Mughal M, Al-Hadithy N. J Plast Reconstr Aesthet Surg. 2014
Aug;67(8):1076-81. doi: 10.1016/j.bjps.2014.04.031. Epub 2014 May
10.National commissioning guidelines: body contouring surgery after massive
weight loss.
References – Update October 2013
1.
Bochicchio GV, De Castro GP, Bochicchio KM, et al. Comparison Study of
Acellular Dermal Matrices in Complicated Hernia Surgery. J Am Coll Surg. 2013
Aug 21
References – Update August 2012
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Avella DM, Podany A, Staveley-O’Carroll KF, et al. Laparoscopic repair of postesophagectomy diaphragmatic hernias using human acellular dermal matrix.
Interact Cardiovasc Thorac Surg. 2011;13(2):248-249.
2. Brown CN, Finch JG. Which mesh for hernia repair? Ann R Coll Surg Engl.
2010;92(4):272-278. Available at:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3025220.
3. Canadian Agency for Drugs and Technologies in Health (CADTH). Biological
Mesh: A Review of Clinical Indications, Clinical Effectiveness, Cost-Effectiveness,
and Clinical Practice Guidelines. Rapid Response Report: Summary with Critical
Appraisal. 2010:1-17.
4. Clinicaltrials.gov. Comparative Effectiveness Multicenter Trial for Adhesion
Characteristics of Ventral Hernia Repair Mesh. ClinicalTrials.gov Identifier:
NCT01355939. 2011. Available at:
5. Janfaza M, Martin M, Skinner R. A preliminary comparison study of two
noncrosslinked biologic meshes used in complex ventral hernia repairs. World J
Surg. 2012;36(8):1760-1764.
6. Kozlow JH, Beil RJ, Chung KC. Repair of symptomatic forearm hernias using
acellular dermal matrix--two case reports. J Hand Surg Am. 2010;35(12):20532056.
7. Musculoskeletal Transplant Foundation (MTF). MTF Signs Marketing Agreement
With ETHICON, Inc., for FlexHD Acellular Dermal Matrix. 2007.
8. Musculoskeletal Transplant Foundation (MTF). FlexHD Acellular Dermis
[prescribing information]. 2010.
9. Pollock TA, Pollock H. Progessive Tension Sutures in Abdominoplasty. A Review
of 297 Consecutive Cases. Aesthet Surg J. 2012 Jun 29.
10. Raulo C, Samama CM, Benhamou D, et al. Prevention of operational
thromboembolic risk in plastic and aesthetic surgery. Analysis of cases, inquiries
of practice and recommendations of professional practices. Ann Chir Plast Esthet.
2012 Jun 26. [Epub ahead of print].
11. Staalesen T, Elander A, Strandell A, et al. A systematic review of outcomes of
abdominoplasty. J Plast Surg Hand Surg. 2012 Jul 2.
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References – Update September 2011
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2.
3.
4.
Colwell AS. Current concepts in post-bariatric body contouring. Obes Surg.
2010 Aug;20(8):1178-82.
Kitzinger HB, Abayev S, Pittermann A, et al. The Prevalence of Body Contouring
Surgery After Gastric Bypass Surgery. Obes Surg. 2011 Jun 4.
Mericli AF, Drake DB. Abdominal contouring in super obese patients: a singlesurgeon review of 22 cases. Ann Plast Surg. 2011 May;66(5):523-7.
van der Beek ES, van der Molen AM, van Ramshorst B. Complications after
body contouring surgery in post-bariatric patients: the importance of a stable
weight close to normal. Obes Facts. 2011;4(1):61-6
References – Update December 2010
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2.
3.
4.
5.
6.
7.
8.
Arthurs ZM, Cuadrado D, Sohn V, et al. Post-bariatric panniculectomy: prepanniculectomy body mass index impacts the complication profile. Am J Surg.
2007 May;193(5):567-70.
Cooper JM, Paige KT, Beshlian KM, et al. Abdominal panniculectomies: high
patient satisfaction despite significant complication rates. Ann Plast Surg. 2008
Aug;61(2):188-96.
Greco JA 3rd, Castaldo ET, Nanney LB, et al. The effect of weight loss surgery
and body mass index on wound complications after abdominal contouring
operations. Ann Plast Surg. 2008 Sep;61(3):235-42.
Leahy PJ, Shorten SM, Lawrence WT. Maximizing the aesthetic result in
panniculectomy after massive weight loss. Plast Reconstr Surg. 2008
Oct;122(4):1214-24.
Ortega J, Navarro V, Cassinello N, Lledó S. Requirement and postoperative
outcomes of abdominal panniculectomy alone or in combination with other
procedures in a bariatric surgery unit. Am J Surg. 2010 Aug;200(2):235-40.
Saxe A, Schwartz S, Gallardo L, et al. Simultaneous panniculectomy and ventral
hernia repair following weight reduction after gastric bypass surgery: is it safe?
Obes Surg. 2008 Feb;18(2):192-5
Shermak MA, Rotellini-Coltvet LA, Chang D. Seroma development following
body contouring surgery for massive weight loss: patient risk factors and
treatment strategies. Plast Reconstr Surg. 2008 Jul;122(1):280-8.
Zuelzer HB, Ratliff CR, Drake DB. Complications of abdominal contouring
surgery in obese patients: current status. Ann Plast Surg. 2010 May;64(5):598604.
References
1. Dumanian GA, Denham W. Comparison of repair techniques for major incisional
hernias. Am J Surg. 2003;185(1):61-65.
2. Aly AS, Cram AE, Chao M, et al. Belt lipectomy for circumferential truncal excess:
The University of Iowa experience. Plast Reconstr Surg. 2003;111(1):398-413.
3. Freeman BG. Body Contouring, Abdominoplasty. eMedicine:. September 11,
2003. Accessed at: http://www.emedicine.com/plastic/topic12.htm
4. Golladay ES. Abdominal hernias. eMedicine General Surgery Topic 2703. San
Francisco, CA: eMedicine.com; updated July 9, 2002. Available at:
http://www.emedicine.com/med/topic2703.htm
5. Cassar K, Munro A. Surgical treatment of incisional hernia. Br J Surg.
2002;89(5):534-545.
6. van Uchelen JH, Werker PM, Kon M: Complications of abdominoplasty in 86
patients. Plast Reconstr Surg 2001 Jun; 107(7): 1869-73.
7. Larson GM. Society of American Gastrointestinal Endoscopic Surgeons (SAGES).
Laparoscopic repair of ventral hernia. Primary Care Physician's Resource Center.
Santa Monica, CA: SAGES; 2001.
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8. Pitanguy I: Evaluation of body contouring surgery today: a 30-year perspective.
Plast Reconstr Surg 2000 Apr; 105(4): 1499-514; discussion 1515-6.
9. Ramirez OM: Abdominoplasty and abdominal wall rehabilitation: a comprehensive
approach. Plast Reconstr Surg 2000 Jan; 105(1): 425-35.
10. Baroudi R, Affonso Ferreira CA: Seroma: How to avoid it and how to treat it.
Aesth Surg J 1999; 18(6): 439-41.
11. Rao RB, Ely SF, Hoffman RS: Deaths related to liposuction. N Engl J Med 1999
340:1471-1475.
12. Shestak KC: Marriage abdominoplasty expands the mini-abdominoplasty concept.
Plast Reconstr Surg 1999 Mar; 103(3): 1020-31; discussion 1032-5.
13. Elbaz JS, Flageul G, Olivier-Masveyraud F. "Classical" abdominoplasty. Ann Chir
Plast Esthet. 1999;44(4):443-461.
14. Micheau P, Grolleau JL. Incisional hernia. Patient management. Approach to the
future operated patients. Ann Chir Plast Esthet. 1999;44(4):325-338.
15. Vastine VL, Morgan RF, Williams GS, et al. Wound complications of
abdominoplasty in obese patients. Ann Plast Surg. 1999;42:34-39.
16. Cardenas-Camarena L, Gonzalez LE. Large-volume liposuction and extensive
abdominoplasty: a feasible alternative for improving body shape. Plast Reconstr
Surg. 1998;102:1698-1707.
17. Mohammad JA, Warnke PH, Stavraky W. Ultrasound in the diagnosis and
management of fluid collection complications following abdominoplasty. Ann Plast
Surg. 1998;41:498-502.
18. Schoeller T, Wechselberger G, Otto A, et al. New technique for scarless umbilical
reinsertion in abdominoplasty procedures. Plast Reconstr Surg. 1998;102:17201723.
19. Cardenas-Camarena L, Gonzalez LE. Large-volume liposuction and extensive
abdominoplasty: A feasible alternative for improving body shape. Plast Reconstr
Surg. 1998;102(5):1698-1707.
20. Lockwood T. Rectus muscle diastasis in males: Primary indication for
endoscopically assisted abdominoplasty. Plast Reconstr Surg. 1998;101(6):16851691.
21. Bridenstine JB. Use of ultra-high frequency electrosurgery (radiosurgery) for
cosmetic surgical procedures. Dermatol Surg. 1998;24(3):397-400.
22. Matarasso A, Matarasso SL. When does your liposuction patient require an
abdominoplasty? Dermatol Surg. 1997;23(12):1151-1160.
23. Nahas FX, Augusto SM, Ghelfond C. Should diastasis recti be corrected? Aesthetic
Plast Surg. 1997;21(4):285-289.
24. O'Brien JJ, Glasgow A, Lydon P. Endoscopic balloon-assisted abdominoplasty.
Plast Reconstr Surg. 1997;99(5):1462-1463.
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27. No authors listed. Update from the Ultrasonic Liposuction Task Force of the
American Society for Dermatologic Surgery. Dermatol Surg. 1997;23(3):211214.
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30. Eaves FF 3rd, Nahai F, Bostwick J 3rd: Endoscopic abdominoplasty and
endoscopically assisted miniabdominoplasty. Clin Plast Surg 1996 Oct; 23(4):
599-616; discussion 617.
31. Lockwood T: The role of excisional lifting in body contour surgery. Clin Plast Surg
1996 Oct; 23(4): 695-712.
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32. Apfelberg DB. Results of multicenter study of laser-assisted liposuction. Clin Plast
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33. Baroudi R, Moraes M: A "bicycle-handlebar" type of incision for primary and
secondary abdominoplasty. Aesthetic Plast Surg 1995 Jul-Aug; 19(4): 307-20.
34. Core GB, Mizgala CL, Bowen JC 3rd, Vasconez LO: Endoscopic abdominoplasty
with repair of diastasis recti and abdominal wall hernia. Clin Plast Surg 1995 Oct;
22(4): 707-22.
35. Matarasso A: Liposuction as an adjunct to a full abdominoplasty. Plast Reconstr
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36. Baroudi R: Body sculpturing. Clin Plast Surg 1984 Jul; 11(3): 419-43.
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