Panniculectomy Medical Necessity Criteria
Abdominoplasty is a surgical procedure performed to tighten loose anterior abdominal wall muscles and remove excess abdominal skin and fat. Abdominoplasty, including diastasis recti repair, is considered a cosmetic procedure.
Panniculectomy may be performed for both medically necessary and cosmetic reasons. The medical need for this procedure must be established by documenting that the enrollee has significant symptoms that cannot be adequately managed with more conservative or less invasive measures.
The following guidelines are used when determining the medical necessity of panniculectomy requests:
1. A statement from the enrollee’s primary care physician recommending panniculectomy surgery.
2. Photographs documenting that the panniculus hangs at or below the level of the pubis.
3. Medical records from the enrollee’s family physician and other treating physicians documenting that the panniculus causes chronic rashes, abscesses, skin irritation, infection, chafing, or dermatitis occurring on opposed surfaces of the skin, that consistently recur over six (6) months of appropriate medical therapy, or remains refractory to appropriate medical therapy over a period of 6 months, despite good hygiene practices.
4. Panniculectomy is requested following significant weight loss, documentation from the patient’s primary care physician indicating that the enrollee’s weight has remained stable for six (6) months is required.
