Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

Abdominoplasty, Panniculectomy and suction Lipectomy are generally not covered services.

1. Paniculectomy is considered medically necessary according to the following criteria:
   1. Panniculus hangs below the level of the pubis; 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, or remains refractory to appropriate medical therapy over a period of 3 months. and
   3. It has not resulted from non-covered surgical weight loss treatments.
      Paniculectomy is considered cosmetic when above criteria are not met.

Codes Used In This BI:

1. Repair of a diastasis recti, defined as a thinning out of the anterior abdominal wall fascia, is not considered medically necessary because, according to the clinical literature, it does not represent a "true" hernia and is of no clinical significance.
2. Abdominoplasty, suction lipectomy, or lipoabdominoplasty are considered cosmetic.