CurrentUnitedHealthcarePolicy CSNC.MP.014.07

Panniculectomy Surgery (for North Carolina Only)

Policy governs coverage guidance for panniculectomy surgery for UnitedHealthcare members in North Carolina and defers to the North Carolina Medicaid Clinical Coverage Policy Reconstructive and Cosmetic Surgery (1-O-1) for clinical coverage criteria. It lists applicable CPT procedure codes and notes state-specific fee-schedule exclusions.

Policy Summary

PayerUnitedHealthcare

PolicyPanniculectomy Surgery (for North Carolina Only)

Policy CodePolicy CSNC.MP.014.07

Change TypeTitle revised; codes removed; informational FDA update; prior version archived

Effective DateNov 1, 2025

Next Review Date

Key ActionWhen determining medical necessity, providers must refer to and document criteria per the North Carolina Medicaid Clinical Coverage Policy Reconstructive and Cosmetic Surgery (1-O-1).

POLICY UPDATE CHANGES

Title changed from 'Panniculectomy and Body Contouring Procedures (for North Carolina Only)' to 'Panniculectomy Surgery (for North Carolina Only)'.

CPT codes 15832-15839 and 15876 removed from Applicable Codes list.

Updated FDA section to reflect most current information.

Archived previous policy version CSNC.MP.014.06.

5CPT codes listed as possibly cosmetic/reconstructive

9CPT codes removed from policy

Coverage Summary & Rationale

This policy governs coverage guidance for panniculectomy surgery for UnitedHealthcare members in North Carolina and defers to the North Carolina Medicaid Clinical Coverage Policy, Reconstructive and Cosmetic Surgery (1-O-1) for clinical coverage criteria determining medical necessity for reconstructive versus cosmetic panniculectomy procedures. It lists applicable CPT procedure codes and notes state-specific fee-schedule exclusions. Effective Date: November 1, 2025. Policy Number: CSNC.MP.014.07.

Coverage Rationale

Coverage determined by referenced state clinical coverage policy

ALL of the following

This Medical Policy only applies to the state of North Carolina.
For clinical coverage criteria, refer to the North Carolina Medicaid (Division of Health Benefits) Clinical Coverage Policy, Reconstructive Surgery: 1-O-1, Reconstructive and Cosmetic Surgery.

Applicable CPT Codes

May be cosmetic; review required to determine if considered cosmetic or reconstructiveCPT

15830	Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy.
15847	Excision, excessive skin and subcutaneous tissue (includes lipectomy), abdomen (e.g., abdominoplasty) (includes umbilical transposition and fascial plication) (List separately in addition to code for primary procedure).
15877	Suction assisted lipectomy; trunk. CPT code marked with an asterisk (*) is not on the NC Medicaid Fee Schedule and may not be covered by NC Medicaid.
15878	Suction assisted lipectomy; upper extremity. CPT code marked with an asterisk (*) is not on the NC Medicaid Fee Schedule and may not be covered by NC Medicaid.
15879	Suction assisted lipectomy; lower extremity. CPT code marked with an asterisk (*) is not on the NC Medicaid Fee Schedule and may not be covered by NC Medicaid.

Removed from policy (no longer listed)CPT

15832	Removed from Applicable Codes per 11/01/2025 revision.
15833	Removed from Applicable Codes per 11/01/2025 revision.
15834	Removed from Applicable Codes per 11/01/2025 revision.
15835	Removed from Applicable Codes per 11/01/2025 revision.
15836	Removed from Applicable Codes per 11/01/2025 revision.
15837	Removed from Applicable Codes per 11/01/2025 revision.
15838	Removed from Applicable Codes per 11/01/2025 revision.
15839	Removed from Applicable Codes per 11/01/2025 revision.
15876	Removed from Applicable Codes per 11/01/2025 revision.

What Providers Must Do

Documentation Required

Follow state clinical coverage policy

When determining medical necessity, providers must refer to and document criteria per the North Carolina Medicaid Clinical Coverage Policy Reconstructive and Cosmetic Surgery (1-O-1).

NC Medicaid Clinical Coverage Policy Reconstructive and Cosmetic Surgery (1-O-1)

Billing Rule

NC Medicaid fee schedule exceptions

CPT codes marked with an asterisk (15877, 15878, 15879) are not on the State of North Carolina Medicaid Fee Schedule and therefore may not be covered by the State program; verify coverage and reimbursement with NC Medicaid.

Affected codes: 15877, 15878, 15879
Verify coverage and reimbursement with NC Medicaid

Background & Definitions

This UnitedHealthcare medical policy applies only to the state of North Carolina. For clinical coverage criteria, medical necessity determinations must refer to the North Carolina Medicaid (Division of Health Benefits) Clinical Coverage Policy, Reconstructive Surgery: 1-O-1 (Reconstructive and Cosmetic Surgery).

The policy is informational and intended to assist interpretation of UnitedHealthcare standard benefit plans; federal, state, or contractual requirements govern if there is a conflict. Providers should verify state-specific coverage and reimbursement rules when applying this policy.

Panniculectomy: Excision of excessive skin and subcutaneous tissue of the abdomen (infraumbilical panniculectomy).

Policy Revision Timeline

11/01/2025revisedLatest

Title changed from 'Panniculectomy and Body Contouring Procedures (for North Carolina Only)' to 'Panniculectomy Surgery (for North Carolina Only)'. (material)

11/01/2025removedLatest

CPT codes 15832, 15833, 15834, 15835, 15836, 15837, 15838, 15839, and 15876 removed from Applicable Codes list. (material)

11/01/2025revisedLatest

Updated FDA section to reflect the most current information; notes panniculectomy procedures are not regulated by the FDA though devices/instruments used may require FDA approval. (informational, non-material)

11/01/2025archived

Archived previous policy version CSNC.MP.014.06. (non-material)