Medical Policy Panniculectomy/ Removal of Redundant Tissue
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Medical Policy
Panniculectomy/
Removal of Redundant Tissue
Subject: Panniculectomy/Removal of Redundant Skin and Subcutaneous Tissue
Background: Panniculectomy is the removal of a large fold of redundant abdominal skin and subcutaneous
tissue. The panniculus can cause various skin problems, such as irritation, rash, inflammation, ulcers, hygiene
issues or hernias as it can hang down over the pubis and groin area. This procedure may be performed after
significant weight loss.
Authorization:
Prior authorization is required for panniculectomy and removal of redundant skin and subcutaneous tissue provided
to members enrolled in commercial (HMO, POS, PPO) products.
Please see HPHC’s Breast Surgeries Medical Review Criteria or HPHC Gynecomastia Medical Review Criteria for
criteria related to removal of excess/redundant breast skin/tissue.
This policy utilizes InterQual® criteria and/or tools, which Harvard Pilgrim may have customized. You may request
authorization and complete the automated authorization questionnaire via HPHConnect at
www.harvardpilgrim.org/providerportal. In some cases, clinical documentation and/or color photographs may be
required to complete a medical necessity review. Please submit required documentation as follows:
• Clinical notes/written documentation —via HPHConnect Clinical Upload or secure fax (800-232-0816)
• Photographs — HPHConnect Clinical Upload function, email (utilization_requests@harvardpilgrim.org), or
mail (Utilization Management, 1600 Crown Colony Dr., Quincy, MA 02169). Please note that photographs
should not be faxed as faxed photos cannot be utilized in making a medical necessity determination.
Providers may view and print the medical necessity criteria and questionnaire via HPHConnect for providers (Select
Resources and the InterQual® link) or contact the commercial Provider Service Center at 800-708-4414. (To
register for HPHConnect, follow the instructions here.) Members may access these materials by logging into their
online account (visit www.harvardpilgrim.org, click on Member Login, then Plan Details, Prior Authorization for
Care, and the link to clinical criteria) or by calling Member Services at 888-333-4742.
Policy and Coverage Criteria:
For this policy, Harvard Pilgrim Health Care (HPHC) draws upon the following InterQual® criteria which HPHC has
customized:
• Panniculectomy, abdominal (Version 2021)
Note: Frontal and lateral colored photographs (taken when the patient is standing erect) documentation
demonstrating the degree of skin redundancy must be mailed or emailed to Harvard Pilgrim Health Care as faxed
photographs cannot be utilized in making a determination of medical necessity.
Removal of Redundant Skin and Subcutaneous Tissue from Anatomical Areas other than Breast or
Abdomen
Removal of redundant skin (e.g., from thighs, hips, buttocks, and/or arms) is considered medically necessary when
documentation confirms ALL the following:
• Weight loss has resulted in significant excess/redundant skin or skin folds; AND
Public Domain
HPHC Medical Policy Page 1 of 5
Panniculectomy/Removal of Redundant Tissue VC09AUG21P
HPHC policies are based on medical science, and written to apply to the majority of people with a given condition. Individual members’ unique
clinical circumstances, and capabilities of the local delivery system are considered when making individual UM determinations.
Coverage described in this policy is standard under most HPHC plans. Specific benefits may vary by product and/or employer group. Please
reference appropriate member materials (e.g. Benefit Handbook, Certificate of Coverage) for member-specific benefit information.• Redundant skin and/or skin folds directly cause ALL of the following:
o A physical functional impairment that interferes with activities of daily living including physical exercise;
AND
o Persistent symptomatic intertriginous ulcerations or macerations that have been refractory to good
personal hygiene and physician-supervised local treatment over a period of several months; AND
Documentation must include a detailed description of all physician-supervised skin treatment
o Recurrent skin infections (i.e. at least 2 episodes within 12 months) that required systemic antibiotics,
and are directly related to the redundant skin
Documentation must confirm episodes are refractory to at least a full course of antibiotic
treatment
Note: Colored photograph documentation demonstrating the degree of skin redundancy must be mailed or emailed
to Harvard Pilgrim Health Care as faxed photographs cannot be utilized in making a determination of medical
necessity.
Same Day Procedures
Panniculectomies are not considered medically necessary in conjunction to other medically necessary procedures
(e.g. hysterectomy, hernia repair) unless the above criteria are met.
Under state mandate, Harvard Pilgrim Health Care (HPHC) considers treatment to correct or repair disturbances of
body composition caused by HIV-associated lipodystrophy syndrome as medically necessary. Medical record
documentation must confirm that treatment is medically necessary for repairing, correcting or ameliorating the
effects of HIV-associated lipodystrophy syndrome.
Exclusions:
Harvard Pilgrim Health Care (HPHC) considers panniculectomy procedures or removal of excess/redundant skin as
not medically necessary for all other indications. In addition, HPHC does not cover:
• Abdominoplasty
• Diastasis recti repair
• Panniculectomy or removal of excess/redundant skin for treatment of psychological or psychosocial issues
related to redundant skin
• Panniculectomy or removal of excess/redundant skin performed at the time of an additional abdominal or
gynecological surgery unless criteria above are met
• Suction lipectomy, unless stated in mandate
• Surgical removal of redundant skin, or body contouring for cosmetic purposes only
• Treatment of neck or back pain
• Cosmetic procedures to reshape body parts to improve the member’s appearance or self-esteem when no
physical functional impairment exists
Supporting Information:
A panniculectomy is a surgical procedure to remove the panniculus or excess skin from the lower abdomen.
Because it hangs down over the pubis and groin area, the panniculus may cause hindrance in healing and various
skin problems (e.g. inflammation, ulcers, skin breakdown). Panniculectomies may be performed after significant
weight loss.
Rasmussen et al. (2017) reported on postoperative outcomes among patients undergoing reconstructive
panniculectomies at the time of gynecologic surgery. This was a retrospective review of patients where age, body
mass index, surgical procedure, estimated blood loss, wound complications were assessed. One-way analysis of
variance and logistic regression were used to evaluate the data from a total of 300 individuals. Complications
Public Domain
HPHC Medical Policy Page 2 of 5
Panniculectomy/Removal of Redundant Tissue VC09AUG21P
HPHC policies are based on medical science, and written to apply to the majority of people with a given condition. Individual members’ unique
clinical circumstances, and capabilities of the local delivery system are considered when making individual UM determinations.
Coverage described in this policy is standard under most HPHC plans. Specific benefits may vary by product and/or employer group. Please
reference appropriate member materials (e.g. Benefit Handbook, Certificate of Coverage) for member-specific benefit information.included 85 (28.3%) cases of superficial cellulitis and 9 (3.0%) cases of surgical-site infection. Diabetes,
hypertension and smoking were significant predictors of postoperative wound complications, as shown from the
logistic regression. The authors concluded panniculectomy combined with gynecologic surgery to be safe and
effective for obese individuals with acceptable incidence of wound infection.
Mioton et al. (2013) conducted a retrospective review of the American College of Surgeons National Surgical
Quality Improvement Program database for all individuals undergoing panniculectomy from 2006 to 2010. Patient
demographics and 30-day outcomes were assessed from a total of 954 panniculectomies that met inclusion criteria.
Risk-adjusted multivariate regression showed that undergoing a panniculectomy by a non-plastic surgeon was a
significant predictor of overall postoperative complications (95% CI, 1.35 to 3.23). Overall, the multivariate
regression analysis showed that panniculectomies performed by plastic surgeons resulted in lower rates of overall
postoperative complications compared with those performed by non-plastic surgeons.
Koulaxouszidis et al. (2012) retrospectively analyzed the clinical course and outcome of 24 individuals receiving
panniculectomies to follow trends of postoperative complications. Complications were categorized as minor or
major based on the individual’s needs of readmission or re-operation. Complex decongestive physical therapy
(CDP) was performed for 4 to 6 weeks preoperatively and 2 weeks postoperatively. The authors found 12 out of 16
patients within the CDP group to have uneventful course, whereas all non-CDP patients had at least one
complication. They concluded that adequate perioperative CDP treatment may reduce early postoperative
complications after resection of panniculus morbidus.
Guidelines:
The American Society of Plastic Surgeons (ASPS) guidelines recommend panniculectomies for obese individuals due
to the removal of the large abdominal apron of fat. According to the ASPS, the severity of abdominal deformities is
graded on the scale below:
Grade 1: Panniculus covers hairline and mons pubis but not the genitals
Grade 2: Panniculus covers genitals and upper thigh crease
Grade 3: Panniculus covers upper thigh
Grade 4: Panniculus covers mid-thigh
Grade 5: Panniculus covers knees and below
Coding:
Codes are listed below for informational purposes only, and do not guarantee member coverage or
provider reimbursement. The list may not be all-inclusive. Deleted codes and codes which are not
effective at the time the service is rendered may not be eligible.
CPT ® Codes Description
15830 Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen,
infraumbilical panniculectomy
15832 Excision, excessive skin and subcutaneous tissue (includes lipectomy); thigh
15833 Excision, excessive skin and subcutaneous tissue (includes lipectomy); leg
15834 Excision, excessive skin and subcutaneous tissue (includes lipectomy); hip
15835 Excision, excessive skin and subcutaneous tissue (includes lipectomy); buttock
15836 Excision, excessive skin and subcutaneous tissue (includes lipectomy); arm
15839 Excision, excessive skin and subcutaneous tissue (includes lipectomy); other area
15877 Suction assisted lipectomy; trunk
15878 Suction assisted lipectomy; upper extremity
Public Domain
HPHC Medical Policy Page 3 of 5
Panniculectomy/Removal of Redundant Tissue VC09AUG21P
HPHC policies are based on medical science, and written to apply to the majority of people with a given condition. Individual members’ unique
clinical circumstances, and capabilities of the local delivery system are considered when making individual UM determinations.
Coverage described in this policy is standard under most HPHC plans. Specific benefits may vary by product and/or employer group. Please
reference appropriate member materials (e.g. Benefit Handbook, Certificate of Coverage) for member-specific benefit information.15879 Suction assisted lipectomy; lower extremity
Non-covered Codes
CPT ® Codes Description
15847 Excision, excessive skin and subcutaneous tissue (includes lipectomy), abdomen (eg,
abdominoplasty) (includes umbilical transposition and fascial plication)
Billing Guidelines:
Member’s medical records must document that services are medically necessary for the care provided. Harvard
Pilgrim Health Care maintains the right to audit the services provided to our members, regardless of the
participation status of the provider. All documentation must be available to HPHC upon request. Failure to produce
the requested information may result in denial or retraction of payment.
References:
1. Acarturk TO, Wachtman G, Heil B, Landecker A, Courcoulas AP, Manders EK. "Panniculectomy as an adjuvant
to bariatric surgery." Annals of Plastic Surgery 2004; 53: 360.
2. ASPS Recommended Insurance Coverage Criteria for Third-Party Payers: Surgical Treatment of Skin
Redundancy for Obese and Massive Weight Loss Patient. http://www.plasticsurgery.org/Documents/medical-
professionals/health-policy/insurance/Surgical-Treatment-of-Skin-Redundancy-Following.pdf
3. Body Contouring Surgical Procedures Physician’s Guide: Panniculectomy (in obese patients). American Society
of Plastic Surgeons. 2017. Available at: https://www.plasticsurgery.org/for-medical-professionals/resources-
and-education/publications/physicians-guide-to-cosmetic-surgery/body-contouring-surgical-procedures-
physician%E2%80%99s-guide?sub=Panniculectomy+(in+obese+patients). Accessed January 12, 2021.
4. Coon D, Gusenoff JA, Kannan N, El Khoudary SR, Naghshineh N, Rubin JP. "Body mass and surgical
complications in the postbariatric reconstructive patient; Analysis of 511 cases." Annals of Surgery 2009; 249:
397.
5. Cooper JM, Paige KT, Beshlian KM, Downey DL, Thereby RC. "Abdominal panniculectomies: High patient
satisfaction despite significant complication rates." Annals of Plastic surgery 2008; 61: 188.
6. Gurunluoglu R. Panniculectomy and Redundant Skin Surgery in Massive Weight Loss Patients. Annals of Plastic
Surgery. 2008;61(6):654-657. doi:10.1097/sap.0b013e3181788e63.
7. Manahan M, Shermak MA. "Massive panniculectomy after massive weight loss". Plastic and Reconstructive
Surgery 2006; 117: 2191.
8. Massachusetts State Mandate: An Act relative to HIV-associated lipodystrophy syndrome treatment. 2018.
Available at: https://malegislature.gov/Bills/189/Senate/S2137. Accessed January 12, 2021.
9. Koulaxouzidis G, Goerke S, Eisenhardt S et al. An Integrated Therapy Concept for Reduction of Postoperative
Complications After Resection of a Panniculus Morbidus. Obes Surg. 2011;22(4):549-554. doi:10.1007/s11695-
011-0561-4.
10. Local Coverage Determination (LCD): Cosmetic and Reconstructive Surgery (L34698). Effective date: 1/1/17.
Accessed January 6, 2021.
11. Meyerowitz BR, Gruber RP, Laub DR. "Massive abdominal panniculectomy." Journal of American Medical
Association 1973; 225, 408.
12. Mioton L, Buck D, Gart M, Hanwright P, Wang E, Kim J. A Multivariate Regression Analysis of Panniculectomy
Outcomes. Plast Reconstr Surg. 2013;131(4):604e-612e. doi:10.1097/prs.0b013e3182818f1f.
13. Panniculectomy for Treatment of Symptomatic Panniculi. Hayesinc.com/subscription/login [via subscription
only]. Accessed January 6, 2021.
14. Rasmussen R, Patibandla J, Hopkins M. Evaluation of indicated non-cosmetic panniculectomy at time of
gynecologic surgery. International Journal of Gynecology & Obstetrics. 2017;138(2):207-211.
doi:10.1002/ijgo.12207.
Public Domain
HPHC Medical Policy Page 4 of 5
Panniculectomy/Removal of Redundant Tissue VC09AUG21P
HPHC policies are based on medical science, and written to apply to the majority of people with a given condition. Individual members’ unique
clinical circumstances, and capabilities of the local delivery system are considered when making individual UM determinations.
Coverage described in this policy is standard under most HPHC plans. Specific benefits may vary by product and/or employer group. Please
reference appropriate member materials (e.g. Benefit Handbook, Certificate of Coverage) for member-specific benefit information.15. Shermak MA. "Hernia repair and abdominoplasty in gastric bypass patients." Plastic and Reconstructive Surgery
2006; 117: 1145.
16. Zannis J, Wood BC, Griffin LP, Knipper E, Marks MW, David LR. "Outcome study of the surgical management of
panniculitis." Annals of Plastic Surgery 2012; 68: 194.
Summary of Changes:
Date Changes
7/21 No changes
1/21 Annual review; coding updated
2/20 Annual review; coding updated
4/19 Criteria maintained; Policy automated through InterQual®
2/19 Reviewed; No changes;
1/19 Reviewed; No changes
5/18 Annual review; no criteria changes
6/17 Background and References updated. Policy coverage criteria updated for panniculectomy and
removal of redundant skin. Same day procedures are an exclusion. Coding was updated.
5/17 Reviewed and reissued
4/16 Minor formatting edits.
4/15 Provide simplified description of panniculectomy procedure.
• Add links to public (member and provider) sites.
• Simplify description of weight loss expectations (member’s weight must be stable for at least
6 months following lifestyle changes or medical intervention, or for at least 12 months
following bariatric surgery).
• Provide simplified description of when occlusive overhanging pannus meets criteria (kept
footnote re: ASPS Grading).
• Add coding profile.
• Expand Exclusions to include procedures performed at the time of an additional abdominal
or gynecological surgery unless criteria are met, and surgical removal of redundant skin, or
body contouring for cosmetic purposes only.
Approved by Medical Policy Committee: 07/20/21
Approved by Clinical Policy Operational Committee: 5/11, 5/12, 2/13, 3/14, 4/15, 4/16, 5/17, 6/17,
5/18, 1/19, 2/19; 4/19; 5/20; 2/21; 8/21
Policy Effective Date: 08/09/21
Initiated: 7/1/10
Public Domain
HPHC Medical Policy Page 5 of 5
Panniculectomy/Removal of Redundant Tissue VC09AUG21P
HPHC policies are based on medical science, and written to apply to the majority of people with a given condition. Individual members’ unique
clinical circumstances, and capabilities of the local delivery system are considered when making individual UM determinations.
Coverage described in this policy is standard under most HPHC plans. Specific benefits may vary by product and/or employer group. Please
reference appropriate member materials (e.g. Benefit Handbook, Certificate of Coverage) for member-specific benefit information.You can also read
