Clinical Policy Bulletin: Abdominoplasty, Suction Lipectomy, and Ventral Hernia Repair
Aetna considers panniculectomy/apronectomy medically necessary according to the following criteria:
Panniculus hangs below level of pubis, documented by photographs; and
The medical records document that the panniculus causes chronic intertrigo (dermatitis occurring on opposed surfaces of the skin, skin irritation, infection or chafing) that consistently recurs over 3 months while receiving appropriate medical therapy (e.g., oral or topical prescription medication), or remains refractory to appropriate medical therapy over a period of 3 months; and
Photographs with pannus lifted to document presence of intertrigo.
Aetna considers panniculectomy/apronectomy cosmetic when these criteria are not met.
Aetna considers panniculectomy/apronectomy experimental and investigational for minimizing the risk of hernia formation or recurrence. There is inadequate evidence that pannus contributes to hernia formation. The primary cause of hernia formation is an abdominal wall defect or weakness, not a pulling effect from a large or redundant pannus.
Aetna considers repair of a true incisional or ventral hernia medically necessary.
Aetna considers repair of a diastasis recti, defined as a thinning out of the anterior abdominal wall fascia, not medically necessary because, according to the clinical literature, it does not represent a "true" hernia and is of no clinical significance.
Aetna considers abdominoplasty, suction lipectomy, or lipoabdominoplasty cosmetic.
In order to distinguish a ventral hernia repair from a purely cosmetic abdominoplasty, Aetna requires documentation of the size of the hernia, whether the ventral hernia is reducible, whether the hernia is accompanied by pain or other symptoms, the extent of diastasis (separation) of rectus abdominus muscles, whether there is a defect (as opposed to mere thinning) of the abdominal fascia, and office notes indicating the presence and size of the fascial defect.
Abdominoplasty, known more commonly as a "tummy tuck," is a surgical procedure to remove excess skin and fat from the middle and lower abdomen and to tighten the muscles of the abdominal wall. The procedure can improve cosmesis by reducing the protrusion of the abdomen. However, abdominoplasty is considered by Aetna to be cosmetic because it is not associated with functional improvements.
Danilla et al (2013) examined if suction-assisted lipectomy (SAL) decreases the incidence of early cardiovascular disease risk factors or its biochemical and clinical risk indicators. A systematic review of the literature was performed by conducting a pre-defined, sensitive search in MEDLINE without limiting the year of publication or language. The extracted data included the basal characteristics of the patients, the surgical technique, the amount of fat extracted, the cardiovascular risk factors and the biochemical and clinical markers monitored over time. The data were analyzed using pooled curves, risk ratios and standardized means with meta-analytical techniques. A total of 15 studies were identified involving 357 patients. In all of the studies, measurements of pre-defined variables were recorded before and after the SAL procedure. The median follow-up was 3 months (interquartile range (IQR) 1 to 6, range of 0.5 to 10.5). The mean amount of extracted fat ranged from 2,063 to 16,300 ml, with a mean ± standard deviation (SD) of 6,138 ± 4,735 ml. After adjusting for time and body mass index (BMI), leptin and fasting insulin were the only markers that were significantly associated with the amount of aspirated fat. No associations were observed for high sensitive C-reactive protein (hCRP), interleukin-6 (IL-6), adiponectin, resistin, tumor necrosis factor-alpha (TNF-α), Homeostasis Model of Assessment (HOMA), total cholesterol, high-density lipoprotein (HDL), low-density lipoprotein (LDL), triglycerides, free fatty acids or systolic blood pressure. The authors concluded that based on the results of this analysis, the authors concluded that there is no evidence to support the hypothesis that subcutaneous fat removal reduces early cardiovascular or metabolic disease, its markers or its risk factors.
Aboelatta and colleagues (2014) stated that lipoabdominoplasty is nearly a daily aesthetic procedure. Despite the emergence of laser-assisted liposuction, to-date, it has not been clearly evaluated combined with abdominoplasty. This prospective study aimed to evaluate the safety and effectiveness of laser-assisted liposuction relative to traditional liposuction combined with high-lateral-tension abdominoplasty. This study investigated 36 consecutive female patients who underwent high-lateral-tension abdominoplasty combined with liposuction of the upper central abdomen and both flanks. The patients were divided into 3 equal groups based on the technique used for liposuction: (i) Group 1 underwent conventional liposuction with abdominoplasty, (ii) Group 2 underwent a mixture of conventional and laser-assisted liposuction with abdominoplasty, and (iii) Group 3 underwent laser-assisted liposuction with abdominoplasty. Patients in groups 2 and 3 had a better aesthetic outcome than those in group 1 with regard to abdominal contour and skin tightness. No major complications were observed in groups 1 and 2. The patients in group 3 had a higher incidence of complications (3 seromas, 3 central necroses and dehiscence), and 1 patient underwent secondary sutures. The authors concluded that laser-assisted liposuction combined with abdominoplasty in the lateral abdomen seems to be a safe technique with good aesthetic outcomes. Although the combined use of laser-assisted liposuction in the lateral and central abdomen can achieve relatively better aesthetic results, it is associated with significant complications, and its use cannot be supported. Moreover, they stated that proper laser parameters in the central abdominal area still need further study.
Repair initial incisional or ventral hernia; reducible
incarcerated or strangulated
Repair recurrent incisional or ventral hernia; reducible
incarcerated or strangulated
Implantation of mesh or other prosthesis for open incisional or ventral hernia repair or mesh for closure of debridement for necrotizing soft tissue infection (List separately in addition to code for the incisional or ventral hernia repair)
Laparoscopy, surgical, repair, ventral, umbilical, spigelian or epigastric hernia (includes mesh insertion, when performed); reducible
Other specified erythematous conditions [chronic intertrigo] [documentation required]
Panniculitis, other site [abdominal]
ICD-9 codes not covered for indications listed in the CPB:
Diastasis of muscle [diastasis recti]
Other congenital anomalies of abdominal wall [congenital diastasis recti]
Other ICD-9 code related to the CPB:
278.00 - 278.02
Overweight and obesity
Bariatric surgery status
The above policy is based on the following references:
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Bridenstine JB. Use of ultra-high frequency electrosurgery (radiosurgery) for cosmetic surgical procedures. Dermatol Surg. 1998;24(3):397-400.
Matarasso A, Matarasso SL. When does your liposuction patient require an abdominoplasty? Dermatol Surg. 1997;23(12):1151-1160.
Nahas FX, Augusto SM, Ghelfond C. Should diastasis recti be corrected? Aesthetic Plast Surg. 1997;21(4):285-289.
O'Brien JJ, Glasgow A, Lydon P. Endoscopic balloon-assisted abdominoplasty. Plast Reconstr Surg. 1997;99(5):1462-1463.
American Society for Dermatologic Surgery. Guiding principles for liposuction. Dermatol Surg. 1997;23(12):1127-1129.
Coleman WP 3rd, Lawrence N. Liposuction. Dermatol Surg. 1997;23(12):1125.
American Society for Dermatologic Surgery. Update from the Ultrasonic Liposuction Task Force of the American Society for Dermatologic Surgery. Dermatol Surg. 1997;23(3):211-214.
Apfelberg DB. Results of multicenter study of laser-assisted liposuction. Clin Plast Surg. 1996;23(4):713-719.
Ramirez OM. Abdominoplasty and abdominal wall rehabilitation: A comprehensive approach. Plast Reconstr Surg. 2000;105(1):425-435.
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Vastine VL, Morgan RF, Williams GS, et al. Wound complications of abdominoplasty in obese patients. Ann Plast Surg. 1999;42(1):34-39.
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.
Larson GM. Laparoscopic repair of ventral hernia. In: SAGES Primary Care Physician's Resource Center. Santa Monica, CA: Society of American Gastrointestinal Endoscopic Surgeons (SAGES); 2001. Available at: http://www.sages.org/primarycare/chapter35.html. Accessed July 16, 2002.
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Dumanian GA, Denham W. Comparison of repair techniques for major incisional hernias. Am J Surg. 2003;185(1):61-65.
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.
State of Minnesota, Health Technology Advisory Committee. Tumescent liposuction. Technology Assessment. St. Paul, MN: HTAC; 2002.
Cooter R, Robinson D, Babidge W, et al. Systematic review of ultrasound-assisted lipoplasty: Update and reappraisal. ASERNIP-S Report No. 17. North Adelaide, SA: Royal Australasian College of Surgeons, Australian Safety and Efficacy Register of New Interventional Procedures -Surgical (ASERNIP- S); 2002.
Patterson J. Outcomes of abdominoplasty. STEER: Succint and Timely Evaluated Evidence Reviews. Bazian Ltd., eds. London, UK: Wessex Institute for Health Research and Development, University of Southampton; 2003; 3(2):1-9.
Pham C, Middleton P, Watkin S, Maddern G. Laparoscopic ventral hernia repair: An accelerated systematic review. ASERNIP-S Report No. 41. North Adelaide, SA: Australian Safety and Efficacy Register of New Interventional Procedures - Surgical (ASERNIP-S); 2004.
Kannan K, Ng C, Ravintharan T. Laparoscopic ventral hernia repair: Local experience. Singapore Med J. 2004;45(6):271-275.
Sanchez LJ, Bencini L, Moretti R. Recurrences after laparoscopic ventral hernia repair: Results and critical review. Hernia. 2004;8(2):138-143.
Egea DA, Martinez JA, Cuenca GM, et al. Mortality following laparoscopic ventral hernia repair: Lessons from 90 consecutive cases and bibliographical analysis. Hernia. 2004;8(3):208-212.
LeBlanc KA. Incisional hernia repair: Laparoscopic techniques. World J Surg. 2005;29(8):1073-1079.
Van Geffen HJ, Simmermacher RK. Incisional hernia repair: abdominoplasty, tissue expansion, and methods of augmentation. World J Surg. 2005;29(8):1080-1085.
Bragg TW, Jose RM, Srivastava S. Patient satisfaction following abdominoplasty: An NHS experience. J Plast Reconstr Aesthet Surg. 2007;60(1):75-78.
Graf R, de Araujo LR, Rippel R, et al. Lipoabdominoplasty: Liposuction with reduced undermining and traditional abdominal skin flap resection. Aesthetic Plast Surg. 2006;30(1):1-8.
Vila-Rovira R. Lipoabdominoplasty. Clin Plast Surg. 2008;35(1):95-104; discussion 105.
Heller JB, Teng E, Knoll BI, Persing J. Outcome analysis of combined lipoabdominoplasty versus conventional abdominoplasty. Plast Reconstr Surg. 2008;121(5):1821-1829.
Halbesma GJ, van der Lei B. The reverse abdominoplasty: A report of seven cases and a review of English-language literature. Ann Plast Surg. 2008;61(2):133-137.
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Pring CM, Tran V, O'Rourke N, Martin IJ. Laparoscopic versus open ventral hernia repair: A randomized controlled trial. ANZ J Surg. 2008;78(10):903-906.
Ollapallil J, Koong D, Panchacharavel G, et al. New method of abdominoplasty for morbidly obese patients. ANZ J Surg. 2004;74(6):504-506.
Reichenberger MA, Stoff A, Richter DF. Dealing with the mass: A new approach to facilitate panniculectomy in patients with very large abdominal aprons. Obes Surg. 2008;18(12):1605-1610.
Umeadi UP, Ahmed AS, Murphy J, Slade RJ. Apronectomy in combination with major gynaecological procedures. J Obstet Gynaecol. 2008;28(5):516-518.
Ahmad J, Eaves FF 3rd, Rohrich RJ, Kenkel JM. The American Society for Aesthetic Plastic Surgery (ASAPS) survey: Current trends in liposuction. Aesthet Surg J. 2011;31(2):214-224.
Staalesen T, Elander A, Strandell A, Bergh C. A systematic review of outcomes of abdominoplasty. J Plast Surg Hand Surg. 2012;46(3-4):139-144.
Kanjoor JR, Singh AK. Lipoabdominoplasty: An exponential advantage for a consistently safe and aesthetic outcome. Indian J Plast Surg. 2012;45(1):77-88.
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.
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.
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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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.
Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.