These services may or may not be covered by all CoOportunity Health plans. Please see your plan documents for your own coverage information. If there is a difference between this general information and your plan documents, your plan will be used to determine your coverage.
Prior authorization is required for abdominoplasty/panniculectomy.
Abdominoplasty/panniculectomy is generally not covered for cosmetic reasons to improve the appearance of the patient, but may be covered subject to the criteria listed below:
Indications that are covered
Panniculectomy: The panniculus must hang below the level of the pubis, and all of the following criteria must be met:
- Chronic and recurrent skin conditions (cellulitis, skin necrosis, open areas) have failed to respond to (or be managed by) conservative medical treatment for 6 months of medically supervised therapy; and
- Physician visit notes are submitted indicating the nature of the skin condition, treatments attempted and the response to treatment as described above in “a”.; and
- Front and lateral photographs demonstrating the size of the pannus and skin condition must be submitted.
- Panniculectomy requests after gastric bypass surgery must meet all criteria above. In addition the member must have attained adequate weight loss and have maintained that weight loss for at least 6 months.
Indications that are not covered
- Abdominoplasty, and associated diastasis recti surgery.
- Any of these procedures when performed for cosmetic reasons.
Abdominoplasty is surgery performed to remove excessive fat and skin from the abdomen. It is usually performed in order to improve the appearance of the patient.
Diastasis recti abdominis is the separation of the rectus muscles of the abdominal wall, which sometimes results in herniation of the abdominal viscera and may occur during pregnancy. It is generally performed as an add on surgery with an abdominoplasty.
Panniculectomy is the surgical excision of the abdominal apron of superficial fat, and may also be referred to as abdominoplasty.
If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.
The services associated with these codes require prior authorization and may or may not be covered based on the criteria listed above:
|15830||Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy|
|15847||Excision, excessive skin and subcutaneous tissue (includes lipectomy), abdomen (eg, abdominoplasty) (includes umbilical transposition and fascial plication) (List separately in addition to code for primary procedure)|
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This information is for most, but not all, CoOportunity Health plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.
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