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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 state that the American Society of Plastic Surgeons outlines practice parameters that are focused on 
the surgical removal of excess skin and fat that occurs in obsess patients or remains following massive weight 
loss. There are numerous procedures and techniques developed to treat the imperfections that result from 
massive weight loss such as abdominoplasty, panniculectomy, circumferential lipectomy, torsoplasty, medial 
thigh lift, and breast reduction. The operative treatment for the correction of the imperfections will vary 
depending on the patients body type, fat deposition pattern, and the amount of weight loss. 
Not only can imperfections from massive weight loss bring patients a dissatisfaction of appearance but it can 
affect functional abilities as well such as difficulty exercising, impaired ambulation, chronic pain, and hygiene 
difficulties. Dermatological issues such as uncontrolled intertrigo, infections and skin necrosis can also 
develop. 
Practice parameters for patients who are preparing to undergo surgery for removal of excess skin and fat are 
screened and assessed preoperatively. This includes screening for depression, diabetes mellitus, 
gastroesophageal reflux disease (GERD), nutritional deficiencies if any, abdominal wall hernias, and 
preoperative lab and diagnostic testing. 
Excess skin that remains after significant weight loss is nearly impossible to rectify with diet, weight loss or 
exercise. Non-surgical candidates are left with very few alternatives for treatment. Alternative treatments such 
as radiofrequency or ultrasound demonstrate minimal effect and result. Surgical candidates should maintain a 
stable weight for 2 to 6 months for body contouring. Those patients who have undergone bariatric surgery 
stable weight is usually reached at 12 to 18 months. 
Sachs et al
 
performed an overview of panniculectomy and some of the indications and clinical significance of 
performing the procedure. Panniculectomy is not a cosmetic procedure and must meet medically necessary 
criteria. The procedure is performed to remove the excess skin and fat incurred from weight gain. This can 
cause large overhanging abdominal skin known as a pannus which can sometimes cover the thighs, hips and 
knees. This excess can cause difficulty with daily activities and cause skin infections and rashes like intertrigo due to irritation and sweating. Typically, patients with skin conditions receive medical treatment with topical 
antifungals, corticosteroids, and antibiotics. 
How far the pannus extends is graded 1 through 5. Grade 1 is the pannus reaching the mons pubis and grade 5 
is the pannus extending to or past the knees. For a patient to qualify for a panniculectomy they usually must fail 
3 months of medical treatment for intertrigo, and the pannus must hang below the level of the pubis and 
confirmed with photography. A panniculectomy is performed to remove the excess skin and fat to relieve the 
associated symptoms and restore normal function. 
Persons who experience dramatic weight loss also can have excess lower abdominal skin which hangs over the 
groin and pubic areas. This causes issues with walking, discomfort and skin irritation as well. Patients who 
have lost weight without surgery must maintain stable weight for at least 6 months prior to undergoing a 
panniculectomy. For those bariatric surgery patients, weight must remain stable for at least 18 months, 
including the most recent 6 months. 
When patients lose large amounts of weight and are left with loose excess skin and fat, additional weight loss 
or exercise will not correct it. A panniculectomy is medically necessary when excess skin and fat impedes the 
patients activities of daily living, ability to perform appropriate hygiene, causes chronic pain, dermatologic 
issues and impairs the ability to walk or exercise. The literature supports providing limited coverage for 
panniculectomy in the treatment of excess skin and fat of the abdomen when the above criteria are met. 
You can find this rule at the Medicare Local Coverage Determination (LCD) L39051: Cosmetic and 
Reconstructive Surgery. 
 
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.