CurrentUniversity Health Alliance (HSA)Policy MPP-0014-120113

Panniculectomy and Abdominoplasty reimbursement

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This policy governs UHA reimbursement for panniculectomy and abdominoplasty procedures when determined medically necessary and meeting specified clinical and administrative criteria; it applies to providers and members under University Health Alliance plans.

Policy Summary

PayerUniversity Health Alliance (HSA)

PolicyPanniculectomy and Abdominoplasty reimbursement

Policy CodePolicy MPP-0014-120113

Change TypeNo material changes

Effective DateJun 2, 2021

Last ReviewNov 27, 2018

Next Review Date

Key ActionPrior authorization is required for panniculectomy and must be requested via the UHA online portal or by contacting UHA to establish a login.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6 monthsrequired stable weight duration before coverage

3 monthsminimum period rashes or ulcers must persist despite treatment

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CurrentUniversity Health Alliance (HSA)Policy MPP-0014-120113

Panniculectomy and Abdominoplasty reimbursement

Customize your policy alerts

Sign up for University Health Alliance (HSA) Policy MPP-0014-120113 alerts

Get alerted when Policy MPP-0014-120113 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

PayerUniversity Health Alliance (HSA)

PolicyPanniculectomy and Abdominoplasty reimbursement

Policy CodePolicy MPP-0014-120113

Change TypeNo material changes

Effective DateJun 2, 2021

Last ReviewNov 27, 2018

Next Review Date

Key ActionPrior authorization is required for panniculectomy and must be requested via the UHA online portal or by contacting UHA to establish a login.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6 monthsrequired stable weight duration before coverage

3 monthsminimum period rashes or ulcers must persist despite treatment

Panniculectomy and Abdominoplasty Coverage Criteria

Panniculectomy / Abdominoplasty coverage criteria

Covered when ALL of the following are met:

ALL of the following

ONE of the following must be present
- Stable weight for at least six months
- Recurrent documented rashes that do not respond to conventional treatment for at least a three-month period
- Documented recurrent or nonhealing ulcers that do not respond to conventional treatment for at least a three-month period
- Functional impairment such as significant difficulty with walking, maintenance of reasonable hygiene, or other activities of daily living
If the procedure is for removal of redundant skin in other body areas (e.g., upper arm, thigh, hip, circumferential trunk), the same criteria above must be met for coverage
Front and lateral view photographs or digital images demonstrating the size of the panniculus and/or other affected body parts and the nature or extent of skin irritation, cellulitis, or skin necrosis are required
Prior authorization is required

ALL of the following

Abdominoplasty (tummy tuck; CPT 15847 when used with CPT 15830) is considered cosmetic and is not covered
Post–bariatric surgery patients should wait 18 months post‑op for panniculectomy

Relevant CPT and Anesthesia Codes

Relevant CPT/Anesthesia codesCPT

00802	Anesthesia for procedures on lower anterior abdominal wall; panniculectomy
15830	Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy
15832	Excision, excessive skin and subcutaneous tissue (includes lipectomy); thigh
15833	Excision, excessive skin and subcutaneous tissue (includes lipectomy); leg
15834	Excision, excessive skin and subcutaneous tissue (includes lipectomy); hip
15835	Excision, excessive skin and subcutaneous tissue (includes lipectomy); buttock
15836	Excision, excessive skin and subcutaneous tissue (includes lipectomy); arm
15837	Excision, excessive skin and subcutaneous tissue (includes lipectomy); forearm or hand
15838	Excision, excessive skin and subcutaneous tissue (includes lipectomy); submental fat pad
15839	Excision, excessive skin and subcutaneous tissue (includes lipectomy); other area

1–10 of 12

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Prior Authorization and Provider Requirements

Prior Authorization

Prior authorization required for panniculectomy

Prior authorization is required for panniculectomy. Submit the prior authorization request via University Health Alliance’s (UHA) online portal; if you do not have a portal login, contact UHA at 808-532-4000 to establish one.

Prior authorization must be obtained before scheduling the procedure.
Use the UHA online portal for submission; call 808-532-4000 to set up access if needed.

Policy Scope and Payment Disclaimer

Policy scope and non-guarantee of payment

Policy purposeThis UHA payment policy is a guide to coverage, the need for prior authorization and other administrative directives; it is not meant to provide instruction in the practice of medicine.

Not a guarantee of paymentEven if a service is indicated as covered, specific provider contract terms and the member's individual benefit plan may apply; this policy is not a guarantee of payment.

Applicability to affiliatesUHA reserves the right to apply this payment policy to all UHA companies and subsidiaries.

Clinical judgmentThe policy should not deter a provider from expressing his/her clinical judgment; UHA recognizes variation in clinical opinions and approaches.

Reconsideration processA provider may request that UHA reconsider the application of medical necessity criteria with supporting documentation.