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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 abdominal lipectomy/panniculectomy is surgical removal of excessive fat and skin from the 
abdomen. When surgery is performed to alleviate such complicating factors as inability to walk normally, 
  
  chronic pain, ulceration created by the abdominal skin fold, or intertrigo dermatitis, such surgery is considered 
reconstructive. Preoperative photographs may be required to support justification and should be supplied upon 
request. You can find this rule in the Local Coverage Determination (LCD) - Cosmetic and Reconstructive 
Surgery (L33428) - Effective July 29, 2021. 
 
The rules say that panniculectomy is considered medically necessary when the panniculus hangs below the 
level of the pubis, and the medical records document that the panniculus causes chronic intertrigo (dermatitis 
occurring on opposed surfaces of the skin, skin irritation, infection or chafing) that consistently recurs over 
three months while receiving appropriate medical therapy, or remains refractory to appropriate medical therapy 
over a period of three months. Panniculectomy is considered experimental and investigational for minimizing 
the risk of hernia formation or recurrence. There is no adequate evidence that pannus contributes to hernia 
formation. The primary cause of hernia formation is an abdominal wall defect or weakness, not a pulling effect 
from a large or redundant pannus. You can find this rule in the Local Coverage Determination (LCD) - 
Cosmetic and Reconstructive Surgery (L33428) - Effective July 29, 2021. 
 
The rules say that if the procedure is being performed following significant weight loss, in addition to meeting 
the criteria noted above, there should be evidence that the individual has maintained a stable weight for at least 
3 to 6 months. If the weight loss is the result of bariatric surgery, abdominoplasty/panniculectomy should 
generally not be performed until at least 18 months after bariatric surgery and only when weight has been 
stable for at least the most recent 3 to 6 months. Medicare does not cover abdominoplasty or panniculectomy 
when performed primarily for any of the following indications, because it is considered not medically 
necessary (this list may not be all-inclusive): 
 
-Treatment of neck or back pain 
-Improving appearance (i.e., cosmesis) 
-Repairing abdominal wall laxity or diastasis recti 
-Treating psychological symptomatology or psychosocial complaints 
-When performed in conjunction with abdominal or gynecological procedures (e.g., abdominal hernia repair, 
hysterectomy, obesity surgery) unless criteria for panniculectomy and abdominoplasty are met separately 
 
You can find this rule in the Local Coverage Determination (LCD) - Cosmetic and Reconstructive Surgery 
(L33428) - Effective July 29, 2021. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.