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The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that medically necessary services are those that are reasonable and necessary for the diagnosis or treatment of an illness or injury. Medically necessary services include services to improve the functioning of a malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). The rules say that services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 411.15(o). The rules say that Abdominal Lipectomy/Panniculectomy are surgical removal of hanging excessive fat and skin in a transverse or vertical wedge from the abdomen but does not include muscle plication or flap elevation. This surgery is considered reconstructive when it is performed to alleviate such complicating factors as inability to walk normally, chronic pain, ulceration created by the abdominal skin fold, or intertrigo dermatitis (dermatitis occurring on opposed surfaces of the skin, skin irritation, infection or chafing). This procedure may be done after weight loss surgery where there has been a great deal of weight loss with significant skin redundancy with complicating factors as above. Abdominal Lipectomy/Panniculectomy Abdominal lipectomy/panniculectomy is considered medically reasonable and necessary when the pannus or panniculus hangs below the level of the symphysis pubis causing one or more of the following conditions: Chronic intertrigo that consistently remains refractory to appropriate medical therapy (e.g., topical antifungals, corticosteroids, antibiotics) over a period of three months.15 Difficulty walking or functional impairment in activities of daily living.15,16 If the procedure is being performed following significant weight loss, in addition to meeting the criteria noted above, there should be evidence that the patient has maintained a stable weight for at least six months.
For patients whose weight loss is the result of bariatric surgery, abdominal lipectomy/panniculectomy should not be performed until at least 18 months after bariatric surgery and only when weight has been stable for at least the most recent six months Limitations: Abdominal Lipectomy/Panniculectomy Repairing abdominal wall laxity, or diastasis recti to improve appearance. Redundancies resulting from weight loss or weight loss surgery when that tissue is without evidence of chronic infection or inflammation that is refractory to conservative treatment as outlined in the indications listed above. Improving appearance. Liposuction used for body contouring, weight reduction or the harvest of fat tissue for transfer to another body region for alteration of appearance or self-image or physical appearance. All other indications unless covered in the section above. You can find this information in Medicare's Local Coverage Determination (LCD): Cosmetic and Reconstructive Surgery (L35090).
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.