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.

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.