Coverage Rationale .............................................................. 1

Documentation Requirements ............................................... 2

Applicable Codes .................................................................. 3

Description of Services ......................................................... 3

This Medical Policy applies to all UnitedHealthcare Commercial benefit plans.

This Medical Policy applies to Individual Exchange benefit plans in all states except for Colorado.

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medically necessary:

to the Medical Policy titled Breast Reconstruction

Medical notes documenting the following, when applicable:

breakdown, etc.)

failed, or contraindicated; include the dates, duration of treatment, and reason for

view of pannus elevated that allows for the evaluation of any skin damage, and a full lateral

The following definitions may not apply to all plans. Refer to the member specific benefit plan document for applicable

to the umbilicus or above, and may include fascial plication of the rectus muscle diastasis and a neoumbilicoplasty (ASPS,

muscle plication, neoumbilicoplasty or flap elevation. A cosmetic Abdominoplasty is sometimes performed at the time of a

functional Panniculectomy (ASPS, 2017).

procedure that removes adipose tissue from the subcutaneous space with the goal of achieving a more desirable body

contour (Wu et al., 2020).

created including subcutaneous fat volume (SFV). QOL was analyzed using the Carolinas Comfort Scale. Propensity

two were non-comparative and three comparative, were included. Meta-analysis of complications among panniculectomy

and conventional laparotomy group revealed no difference in either intra- or post-operative complication rates. Moreover,

no difference was reported in surgical site complications (p = 0.59), while wound breakdown rates were significantly

management of EC can be considered a safe procedure in selected patients and presents with comparable outcomes to

conventional laparotomy procedures with regard to non-surgical and surgical site complications and improved wound

breakdown rates. The authors noted that the outcomes must be cautiously interpreted because of the limited number of

Sosin et al. (2020) conducted a systematic meta-analysis to assess the durability, complication profile, and safety of

identified as surgical-site occurrence and hernia recurrence. Secondary outcomes included review of techniques used and

appearance in the absence of any signs or symptoms of functional abnormalities, the procedure should be considered

cosmetic in nature and not a compensable procedure unless specified in the patient's policy. ASPS further recommends

that a panniculectomy should be considered a reconstructive procedure when performed to correct or relieve structural

defects of the abdominal wall, improve skin health within the fold beneath the pannus, and/or help improve chronic low

back pain due to functional incompetence of the anterior abdominal wall. In rare circumstances, plastic surgeons may

perform a hernia repair in conjunction with an abdominoplasty or panniculectomy. A true hernia repair involves opening

fascia and/or dissection of a hernia sac with return of intraperitoneal contents back to the peritoneal cavity. A true hernia

repair should not be confused with diastasis recti repair, which is often part of a standard abdominoplasty.

In a practice parameter, ASPS (2017) noted panniculectomy could be considered as a functional correction in patients

SOGC clinical practice guideline for gynecologic surgery for patients with obesity (Yong et al., 2019) reviews the evidence

for panniculectomy performed concurrently with gynecologic surgeries. The guideline notes that studies in this area have

been primarily small, retrospective, and/or non-comparative studies. The authors indicated that panniculectomy can be

considered at the time of open hysterectomy in patients with obesity, although it is rarely performed; and when a

combined procedure is done, consideration should be given to postoperative antibiotics.

Body contouring procedures are typically performed for cosmetic purposes. Body contouring procedures can include, but

procedures simultaneously in a single surgical procedure. All patients underwent surgery between 2016 and 2020. The

patients studied were divided into 4 groups according to the number of anatomical areas operated on. A total of 1254

body contouring procedures were included in the study with a mean of 17 months. The study found that the number of

blood transfusions were statically significantly higher in the IV group (22 patients) than in the other three groups (p value =

0.001). There were no blood transfusions in groups I and II. In comparison to other studies, the average hospital stay was

1.25 days. The overall complication rate (major and minor) was 105 cases (16.07%) in all groups. Patient satisfaction was

highest in patients who underwent 2-3 procedures within the same surgical setting compared to patients who underwent +

3 procedures. The author concluded performing 2 to 3 combined cosmetic procedures in the same surgical setting did not

significantly increase the overall complication rates in the study, but four or more combined procedures were associated

medical complications (p = .047), surgical complications (p < .001), related readmission (p < .001), and related

reoperation (p < .001) were significantly higher in patients undergoing functional panniculectomy. Surgical complications

significantly higher in functional panniculectomy included superficial incisional infection (p < .001), deep incisional

infection (p < .001), organ/space infection (p < .001), dehiscence (p = .003), and bleeding requiring transfusion (p = .003).

The researchers concluded functional panniculectomy have increased risk of superficial incisional infection, deep

incisional infection, organ/space infection, dehiscence, bleeding requiring transfusion, and sepsis compared to patients

undergoing cosmetic abdominoplasty. These adverse events are associated with specific preoperative comorbidities in

these patients.

ElAbd et al. (2021) performed a systematic review and meta-analysis to evaluate the effect of body contouring surgery

contouring surgery for selected patients after massive weight loss following bariatric surgery. Future studies should

attempt to adjust for certain confounding variables, such as the type of bariatric and body contouring surgery performed,

the weight of skin excised during body contouring surgery, and the number of body contouring procedures performed and

their effects on weight loss parameters.

In a systematic review, Jessen et al. (2021) sought to describe surgical techniques used to correct abdominal rectus

diastasis and to investigate recurrence rates and other postoperative complications in relation to the different surgical

techniques. A total of 61 studies met inclusion criteria: 46 used an open approach and 15 used a laparoscopic approach

for repair of the abdominal rectus diastasis. The most common repair was by the classic open low abdominoplasty with a

transverse incision. Laparoscopic techniques were also used. All repairs included a plication of the rectus sheath. In the

concluded many different techniques can be used in the correction of abdominal rectus diastasis. In the current literature,

prevalence of, the desire for, and barriers to BCS (secondary outcomes). Randomized controlled trials, cohort, cross-

sectional, case-control, and longitudinal studies were systematically searched in PubMed, Embase, the Cochrane Central,

and Web of Science. After screening 1923 potential records, 24 studies (representing 6867 participants) were deemed

eligible. Only 18.5% of respondents from cross-sectional studies underwent BCS, with abdominal BCS as the most

common procedure. Most participants desired BCS but listed "cost" and "lacking reimbursement" as the main barriers.

The authors concluded the results suggest that most post-bariatric patients who underwent BCS experienced

improvements in their HRQoL, which could be seen in almost every dimension evaluated, including body image and

not only as an aesthetic supplement but also as a vital part of functional recovery in the surgery-mediated weight loss

journey and, thus, provide it to more post-bariatric patients.

design, surgical procedure, follow-up time, functional outcome and assessment instruments were compiled. All included

studies reported improvements in a variety of functional aspects regardless of surgical method. The outcomes assessed

include core stability, back pain, abdominal pain, posture, urinary incontinence, abdominal muscle strength and quality of

functional disability, however, the absence of standardized instruments for assessing outcome makes it impossible to

compare studies. Since indications for surgery are relative and related to core function, the authors recommended valid

instruments for assessing indication and outcome are needed to ensure benefit of the procedure. The study was limited

by the number of studies included in the review and a low level of evidence in some of the included studies.

In a systematic review, Gormley et al. (2020) reviewed the effect of rectus plication on abdominal strength, function, and

significant improvement. The overall complication rate was 17.0%. The authors noted rectus plication is commonly

performed during abdominoplasty to improve abdominal form and function. They concluded that while the literature to

Heterogeneity in patient population, outcome measures, and comparison groups limit the strength of the authors’

standardizing outcomes in this population.

Wu et al. (2020) note liposuction is the second most commonly performed cosmetic surgery in the United States. Suction-

assisted lipectomy, more commonly known as liposuction, is an outpatient procedure that removes adipose tissue from

the subcutaneous space with the goal of achieving a more desirable body contour. It is the second most commonly

of 35 and 64. Liposuction is used to achieve body contouring by removing excess fat deposits in undesirable areas of the

In a practice parameter, ASPS (2017) indicates the timing for body contouring surgery is ideally performed after the

patient maintains a stable weight for 2 to 6 months. For post bariatric surgery patients, this often occurs 12-18 months

after surgery or at the 25 kg/mg

panniculectomy with limited tissue undermining and/or reduction mammaplasty may be necessary to increase the

body weight more refined body contouring surgery may be performed to address aesthetic issues.