Appeal type: unknown
Decision: unknown

 
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 cosmetic surgery and related services, except as required for the prompt repair of accidental 
injury or to improve the functioning of a malformed body member, is not covered. You can find this rule at 42 
CFR Section 411.15(h). 
 
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). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
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. 
 
Palmetto GBA considers panniculectomy 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 3 months 
while receiving appropriate medical therapy, or remains refractory to appropriate medical therapy over a period 
of 3 months. 
 
Palmetto GBA considers panniculectomy 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. 
 
Note: 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. 
 
Palmetto GBA 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 
Local Coverage Determination (LCD): Cosmetic and Reconstructive Surgery (L33428). 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.