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Effective Date: 12/08/2010 |
Title: Abdominoplasty
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Revision Date:
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Document: BI284:00
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CPT Code(s): 15830, 15847, 15877
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Public Statement
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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.
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Medical Statement
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- Paniculectomy is considered medically necessary according to the following criteria:
- Panniculus hangs below the level of the pubis; 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, or remains refractory to appropriate medical therapy over a period of 3 months. and
- 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: | 15830 | Exc skin abd | | 15847 | Exc skin abd add-on | | 15877 | Suction assisted lipectomy |
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Limits
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- 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.
- Abdominoplasty, suction lipectomy, or lipoabdominoplasty are considered cosmetic.
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Background
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In order to distinguish a ventral hernia repair from a purely cosmetic abdominoplasty, QualChoice 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 QualChoice to be cosmetic because it is not associated with functional improvements.
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Application to Products
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This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.
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Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.
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