Thursday, December 13, 2007

Panniculectomy vs Abdominoplasty

I posted this information back in July, but I thought it would be worth sharing again. As the number of gastric bypass and lap band procedures increase, the number of patients who need this information just continues to grow.
You’ve had your gastric bypass and have lost over 100 lbs. Now you have "all this loose, saggy skin that just hangs" and you have "rashes under the fold all the time". Will your insurance pay for a tummy tuck? Probably not what you are thinking of as a tummy tuck. They may pay for a panniculectomy, but not an abdominoplasty. So let me try to tell you the difference between the two. Photo from article (see below).

Panniculectomy is the removal of the loose (excess) skin and fat tissue below the belly button (umbilicus). Nothing is done to the (possible/probable) loose skin above the belly button. It is strictly to help remove the overhanging skin that is trapping moisture and creating a hygiene and chronic rash problem. It is not meant to improve your overall body shape.

An abdominoplasty is the removal of the loose (excess) skin and fat tissue from the abdomen (stomach area) with transposition of the skin around the umbilicus (the belly button doesn’t usually get moved, the skin around it does) and often tightening (plication) of the abdominal muscles. This creates a more pleasing shape as it addresses the entire abdomen. It is not just a functional surgery, but a cosmetic one.

Look at the above photos. The one on the left with minimal upper body excess skin might get both the functional and improved body shape (cosmetic result) with the panniculectomy. The one on the right would still have the "upper" skin roll as this is from skin above the umbilicus. So by definition, the panniculectomy would not do anything to improve this. The insurance company (see the California BC restrictions) would probably not be persuaded to make an exception for a full abdominoplasty which is what she would need. Chances are this person gets skin irritation below the upper roll also. Frustrating, isn’t it?

Prior to this year (2007) when a surgeon coded the surgical procedure for a panniculectomy or an abdominoplasty the same code was used. This made it difficult (without reading the operative note) to truly tell what had been done.
CPT 15831 Excision, excessive skin and subcutaneous tissue (including lipectomy);abdomen (abdominoplasty)

As of this year the coding has changed which makes it more clear to an insurance company what has been done for the patient. Perhaps it will also help clarify for the patient that a "cosmetic tummy tuck" is not what they will get (unless they are willing to pay the difference) when a panniculectomy is done. The new codes are:
CPT 15830 Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy
CPT 15847 Excision, excessive skin and subcutaneous tissue (includes lipectomy), abdomen (eg abdominoplasty) (includes umbilical transposition and fascial plication) (List separately in addition to code for primary procedure)
Use 15847 in conjunction with 15830

To know whether your insurance policy will help you out with this issue, check your policy or call your insurance provider. Here is BC of California’s policy on the issue. Here is Cigna's. Many insurance companies have similar policies. Some consider it all cosmetic.


Photo--A Classification of Contour Deformities after Bariatric Weight Loss: The Pittsburgh Rating Scale; Plastic & Reconstructive Surgery. 116(5):1535-1544, October 2005; Song, Angela Y. M.D.; Jean, Raymond D. M.D.; Hurwitz, Dennis J. M.D.; Fernstrom, Madelyn H. Ph.D.; Scott, John A. M.S.; Rubin, J Peter M.D.
ASPRS Recommendations for Third-Party Payers--Surgical Treatment of Skin Redundancy for Obese and Massive Weight Loss Patients

17 comments:

Buckeye Surgeon said...

I've had a couple patients over the past year come in with necrotizing soft tissue infections of the pannus. It's disgusting. After the wounds had granulated I referred them to a plastic surgeon for formal panniculectomy.

rlbates said...

I agree, necrotizing soft tissue infections are disgusting for all involved. Wish they never happened.

All This Trouble... said...

How enlightening! I'm a nurse but I've never had much experience in plastic surgery. I've entertained the idea of a "tummy tuck" and now I know exactly what that means and entails. Thanks, Doc!

rlbates said...

You're so welcome.

Kim said...

Thank you so much for the information. I have not had weight loss surgery but have lost 70 pounds through low calorie diet and exercise. I have about 30 more pounds to lose though and already have loose skin. I recently visited a plastic surgeon and was given quotes for a breast lift, panniculectomy and arm lift. I had never heard the term panniculectomy before so here I am doing research. Your info is the best I have found so far, so again I thank you.

Best regards,

Kim

Anonymous said...

I have been referred to a plastic surgeon to correct a diastasis in my recti-abdominals due to pregnancy. They are suggesting a Panniculectomy. Do you thing abdominalplasty is more suiting? Which one is "sewing my abs back together"? I really don't have a problem with the lose skin.

rlbates said...

Anonymous (10-22-09), I can't answer the question of how much skin you need removed as I have not examined you. However, if insurance is involved both CPT 15830 and CPT 15847 will need to be used, as only the 15847 covers the plication of you muscle diastasis.

Anonymous said...

I am a PTA student, and I am looking for surgeon who can remove a "possible pannus" for a patient of mine (her medical Dr is calling it a pannus). It is not on the abdomen, but on her left thigh, and now seems to be spreading onto her calf. We thought we found a plastic surgeon through a website, but he no longer does this type of procedure. She is morbidly obese (500+) but this pannus needs to be remove, it's limiting her physical therapy. The pannus weighs between 50 & 70 Lbs. Can you or do you know of any Dr. that can possibly remove it.
Thanks
Heidi

rlbates said...

Annonymous (Nov 9, 2009) -- I don't know where your patient lives, but look for either a general surgeon or plastic surgeon.

jennygurl78 said...

My mother is morbidly obese and has severe skin breakdown under the skin fold of her stomach. Her insurance is through United Healthcare. In your experience, just in general, if a patient can prove there is severe skin ulceration, interference with ambulation and ADLs, and photo documentation of the overhang, will an insurance company usually over a panniculectomy?

rlbates said...

JennyGurl78, in general, yes. You should call your insurance and ask what they expect of you, which surgeons/plastic surgeons are in your network, if you need a referral, etc. Precertification will most likely be needed.

Anonymous said...

I just seen a dr in Little Rock and am having the panniculectomy in Dec but the way you explain only the lower belly is done the way I understood it will be pulled together Am I wrong and does some of the back get pulled as well????

rlbates said...

Anon (Nov 10), a panniculectomy only removes the lower abdominal excess skin/fat apron.

Anonymous said...

Thanks for the information! Very good info & it helped clarify it a lot for me.

sam speron said...

Thank you for posting this information this could help for others like you

Jamie said...

I've lost 137 pounds the last two years, I have been approved from my South Dakota Wellmark to have a breast reduction (which mind you would take me from a DDD to a very small B-which is why I don't want that, instead have agreed I would pay for a lift with some reduction) I've also been approved for a 15830-excision skin bad infra umbilical panniculectomy-should I be looking into something else? Or maybe ask the doctors office to recode?? Struggling for the right direction!

rlbates said...

Jamie, I would caution you to perhaps ask for a large B or small C as the end result of the breast reduction. Otherwise (and you may prefer this) you may be wishing you'd remained a bit larger with the "lift effect" of the reduction and be asking for an augmentation. Remember you have input on the resulting size and can get the relief of rash reduction, back ache reduction, etc with going from a DDD to a C cup.

Regarding the abdomen, it's hard to say what you should do as I don't know where your excise skin is (above the umbilicus, below, or both). If you have concerns, have another discussion with your plastic surgeon. Perhaps take this post with you to help you explain your concerns.

Best to you.