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 a panniculectomy will be considered medically necessary when the pannus or 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 or remains refractory to appropriate medical therapy (e.g. topical antifungals, 
corticosteroids, antibiotics) over a period of 3 months. 
1. When surgery is performed to alleviate such complicating factors as inability to walk 
normally due to pannus size, chronic pain, ulceration created by the abdominal skin fold, 
or intertrigal dermatitis, such surgery is considered reconstructive. Preoperative 
photographs may be required to support justification and should be supplied upon 
request. 
2. This procedure may also be medically necessary for the patient that has had a significant 
weight-loss following the treatment of morbid obesity, in addition to meeting the criteria 
noted above, there should be evidence that the individual has maintained a stable weight 
for at least 6 months. If the weight loss is the result of bariatric surgery, 
abdominoplasty/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 6 
months and infection and inflammation has continued for the most recent 3 months. The rules say that a mastectomy with nipple preservation or reduction mammoplasty is considered 
reconstructive and a covered service for males with gynecomastia Grade III and IV or abnormal breast 
development with redundancy. 
A. Persists more than 3 to 4 months after the pathological causes are ruled out (e.g., not limited to 
testosterone deficiency, testicular tumor, liver disease, or drug induced). 
B. Persists after 3 to 4 months of unsuccessful medical treatment for pathological gynecomastia. 
C. Pain or tenderness directly related to the breast tissue which has a clinically significant impact upon 
activities of daily living. 
D. Clinical symptoms refractory to a trial of analgesics or anti-inflammatory agents. 
E. For significant clinical manifestations when the excessive breast weight adversely affects the supporting 
structures of the shoulders, neck and trunk. 
Local Coverage Determination (LCD): Cosmetic and Reconstructive Surgery (L39506). 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.