This policy version was replaced October 31, 2022. To find the newest version, go to https://www.bluecrossmn.com/providers/medical-policy-and-utilization-management, read and accept the Blue Cross Medical Policy Statement, then select “Blue Cross and Blue Shield of Minnesota Medical Policies.” This will bring up the Medical Policy search screen. Enter the policy number without the version number (last 3 digits).

In the majority of circumstances, excision of excess skin or tissue is a cosmetic service. In certain locations of the body; however, this excess skin or tissue may create environments that are susceptible to skin infections. Such areas may include the abdomen, buttocks, thighs and upper arms.

Medical management by the application of skin barriers, moisture-absorbing agents, and/or the use of supportive garments is indicated as the first line of treatment. When the condition is persistent and remains refractory to standard, conservative treatment, surgical removal of the excess skin or tissue may be necessary. Examples of surgical procedures to remove excess skin or tissue include: panniculectomy, buttock lift, thigh lift, leg lift, or arm lift.

Definitions

Abdominoplasty:  A procedure to remove excess abdominal skin and fat with or without tightening lax anterior abdominal wall muscles and with or without repositioning or reconstructing the navel.

Brachioplasty:  A procedure to remove loose skin and excess fat in the upper arm. Also called an "arm lift."

Cosmetic Services:  Surgery and other services performed primarily to enhance or otherwise alter physical appearance without correcting or improving a physiological function.

Costal margin:  Lower edge of the chest (bottom of the rib cage).

Diastasis recti:  Separation between the left and right side of the rectus abdominus, the muscle that covers the front of the abdomen. Diastasis recti appears as a ridge running down the midline of the abdomen from the bottom of the breastbone to the navel. Diastasis recti does not represent an abdominal wall hernia.

Imbrication:  Overlapping of tissue. In excision of excessive skin or tissue, it is used to contour tissue in the surgical area.

Lipectomy:  Surgical removal of fatty tissue beneath the skin.

Panniculectomy:  A procedure to remove fatty tissue and excess skin (pannus/panniculus) hanging down from the lower to middle portions of the abdomen.

Symphysis pubis:  The area in the groin where the left and right pubic bones are joined.

Umbilicus:  The navel. It is the scar on the abdomen at the site of the attachment of the umbilical cord.

NOTE: 

• The scope of this policy does not address primary circumcision of newborns or infants.
• Coverage may be subject to legislative mandates, including but not limited to the following, which apply prior to the policy statements:
  • Federal Women’s Health and Cancer Rights Act (WHCRA)
  • Minnesota Statute 62A.25 Reconstructive Surgery

I.  Panniculectomy

• Panniculectomy with or without abdominoplasty may be considered MEDICALLY NECESSARY AND APPROPRIATE when ALL of the following criteria are met:
  • The pannus/panniculus extends at or below the level of the symphysis pubis; AND
  • The treating physician has documented that the pannus/panniculus is associated with:
    1. Chronic or recurrent infection, intertrigo or skin necrosis refractory to at least three months of medical management (e.g., antifungal, antibacterial, and moisture-absorbing agents; supportive garments, topically-applied skin barriers); OR
    2. Chronic or recurrent ulcerations, accompanied by skin deterioration, that are nonresponsive to aggressive wound management;
  • AND 
  • When the panniculectomy is associated with significant weight loss, weight has remained stable for a minimum of six months.
• Panniculectomy with or without abdominoplasty may be considered MEDICALLY NECESSARY AND APPROPRIATE as an adjunct to a medically necessary procedure when needed for exposure to improve surgical access or wound healing following surgery.
• The following procedures are considered COSMETIC as they are performed primarily to enhance or otherwise alter physical appearance without correcting or improving a physiological function:
  • Panniculectomy with or without abdominoplasty not meeting the medical necessity criteria in the policy statements directly above;
  • Abdominoplasty;
  • Nonfunctional procedures performed in association with a medically necessary panniculectomy (e.g., transposition of the umbilicus, undermining to the costal margin, lateral contouring imbrications, lipectomy);
  • Repair of diastasis recti.

II.  Excision of Redundant Skin or Tissue of Other Anatomical Areas

• Excision of redundant skin or tissue of other anatomical areas including but not limited to the upper extremities (e.g., brachioplasty), lower extremities, buttocks, or genitalia may be considered MEDICALLY NECESSARY AND APPROPRIATE when at least ONE of the following are met:
  • The treating physician has documented that the redundant skin is associated with:
    1. Chronic or recurrent infection, intertrigo or skin necrosis refractory to at least three months of medical management (e.g., antifungal, antibacterial, and moisture-absorbing agents; supportive garments, topically-applied skin barriers); OR
    2. Chronic or recurrent ulcerations, accompanied by skin deterioration, that are nonresponsive to aggressive wound management OR
    3. Biopsy or removal of a premalignant or malignant skin lesion.
• Excision of redundant skin or tissue performed primarily to enhance or otherwise alter physical appearance is considered COSMETIC.

Documentation Submission

Documentation supporting the medical necessity criteria described in the policy must be included in prior authorization requests, when prior authorization is required. In addition, the following documentation must be submitted with the prior authorization request:

• Photographs of the affected area, including a lateral photograph of the panniculus.
• Documentation from the medical records of the treating provider of the measures that were used to treat the chronic or recurrent skin infection.

Link to Pre-Authorization Form: https://www.bluecrossmn.com/sites/default/files/DAM/2021-12/BCBSMN-Pre-Auth-Request-fillable-X18509R07.pdf