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Aetna Aetna
Clinical Policy Bulletin:
Abdominoplasty, Suction Lipectomy, and Ventral Hernia Repair
Number: 0211


Policy

  1. Aetna considers panniculectomy/apronectomy medically necessary according to the following criteria:

    1. Panniculus hangs below level of pubus, documented by photographs; and
    2. 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
    3. 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.

  2. Aetna considers repair of a true incisional or ventral hernia medically necessary.

  3. 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.  

  4. Aetna considers abdominoplasty, suction lipectomy, or lipoabdominoplasty cosmetic.



Background

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.
 
CPT Codes / HCPCS Codes / ICD-9 Codes
CPT codes covered if selection criteria are met:
15830
49560
49561
49565
49566
+ 49568
49652
49653
49654
49655
49656
49657
CPT codes not covered for indications listed in the CPB:
+ 15847
15877
ICD-9 codes covered if selection criteria are met:
278.1 Localized adiposity [panniculus adiposus] [documentation required]
551.20 - 551.29 Ventral hernia with gangrene
552.20 - 552.29 Ventral hernia with obstruction
553.20 - 553.29 Ventral hernia
695.89 Other specified erythematous conditions [chronic intertrigo] [documentation required]
729.39 Panniculitis, other site [abdominal]
ICD-9 codes not covered for indications listed in the CPB:
728.84 Diastasis of muscle [diastasis recti]
756.79 Other congenital anomalies of abdominal wall [congenital diastasis recti]
Other ICD-9 code related to the CPB:
278.00 - 278.02 Overweight and obesity
V45.86 Bariatric surgery status


The above policy is based on the following references:
  1. Core GB, Mizgala CL, Bowen JC 3rd, Vasconez LO. Endoscopic abdominoplasty with repair of diastasis recti and abdominal wall hernia. Clin Plast Surg. 1995;22(4):707-722.
  2. Lockwood T. Rectus muscle diastasis in males: Primary indication for endoscopically assisted abdominoplasty. Plast Reconstr Surg. 1998;101(6):1685-1691.
  3. Bridenstine JB. Use of ultra-high frequency electrosurgery (radiosurgery) for cosmetic surgical procedures. Dermatol Surg. 1998;24(3):397-400.
  4. Matarasso A, Matarasso SL. When does your liposuction patient require an abdominoplasty? Dermatol Surg. 1997;23(12):1151-1160.
  5. Nahas FX, Augusto SM, Ghelfond C. Should diastasis recti be corrected? Aesthetic Plast Surg. 1997;21(4):285-289.
  6. O'Brien JJ, Glasgow A, Lydon P. Endoscopic balloon-assisted abdominoplasty. Plast Reconstr Surg. 1997;99(5):1462-1463.
  7. American Society for Dermatologic Surgery. Guiding principles for liposuction. Dermatol Surg. 1997;23(12):1127-1129.
  8. Coleman WP 3rd, Lawrence N. Liposuction. Dermatol Surg. 1997;23(12):1125.
  9. 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.
  10. Apfelberg DB. Results of multicenter study of laser-assisted liposuction. Clin Plast Surg. 1996;23(4):713-719.
  11. Ramirez OM. Abdominoplasty and abdominal wall rehabilitation: A comprehensive approach. Plast Reconstr Surg. 2000;105(1):425-435.
  12. Elbaz JS, Flageul G, Olivier-Masveyraud F. 'Classical' abdominoplasty. Ann Chir Plast Esthet. 1999;44(4):443-461.
  13. Micheau P, Grolleau JL. Incisional hernia. Patient management. Approach to the future operated patients. Ann Chir Plast Esthet. 1999;44(4):325-338.
  14. Vastine VL, Morgan RF, Williams GS, et al. Wound complications of abdominoplasty in obese patients. Ann Plast Surg. 1999;42(1):34-39.
  15. 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.
  16. 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.
  17. Cassar K, Munro A. Surgical treatment of incisional hernia. Br J Surg. 2002;89(5):534-545.
  18. Dumanian GA, Denham W. Comparison of repair techniques for major incisional hernias. Am J Surg. 2003;185(1):61-65.
  19. 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.
  20. Golladay ES. Abdominal hernias. eMedicine General Surgery Topic 2703. Omaha, NE: eMedicine.com; updated July 9, 2002. Available at: http://www.emedicine.com/med/topic2703.htm. Accessed April 22, 2004.
  21. State of Minnesota, Health Technology Advisory Committee. Tumescent liposuction. Technology Assessment. St. Paul, MN: HTAC; 2002.
  22. 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.
  23. 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.
  24. 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.
  25. Kannan K, Ng C, Ravintharan T. Laparoscopic ventral hernia repair: Local experience. Singapore Med J. 2004;45(6):271-275.
  26. Sanchez LJ, Bencini L, Moretti R. Recurrences after laparoscopic ventral hernia repair: Results and critical review. Hernia. 2004;8(2):138-143.
  27. 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.
  28. LeBlanc KA. Incisional hernia repair: Laparoscopic techniques. World J Surg. 2005;29(8):1073-1079.
  29. Van Geffen HJ, Simmermacher RK. Incisional hernia repair: abdominoplasty, tissue expansion, and methods of augmentation. World J Surg. 2005;29(8):1080-1085.
  30. Bragg TW, Jose RM, Srivastava S. Patient satisfaction following abdominoplasty: An NHS experience. J Plast Reconstr Aesthet Surg. 2007;60(1):75-78.
  31. 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.
  32. Vila-Rovira R. Lipoabdominoplasty. Clin Plast Surg. 2008;35(1):95-104; discussion 105.
  33. Heller JB, Teng E, Knoll BI, Persing J. Outcome analysis of combined lipoabdominoplasty versus conventional abdominoplasty. Plast Reconstr Surg. 2008;121(5):1821-1829.
  34. 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.
  35. den Hartog D, Dur AH, Tuinebreijer WE, Kreis RW. Open surgical procedures for incisional hernias. Cochrane Database Syst Rev. 2008;(3):CD006438.
  36. 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.
  37. Ollapallil J, Koong D, Panchacharavel G, et al. New method of abdominoplasty for morbidly obese patients. ANZ J Surg. 2004;74(6):504-506.
  38. 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.
  39. Umeadi UP, Ahmed AS, Murphy J, Slade RJ. Apronectomy in combination with major gynaecological procedures. J Obstet Gynaecol. 2008;28(5):516-518.
  40. 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.
  41. 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.
  42. Kanjoor JR, Singh AK. Lipoabdominoplasty: An exponential advantage for a consistently safe and aesthetic outcome. Indian J Plast Surg. 2012;45(1):77-88.


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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.
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