INSURANCE ISSUES: ABDOMINOPLASTY: RECOMMENDED CRITERIA FOR THIRD-PARTY PAYER COVERAGE

Background:
The American Society of Plastic Surgeons (ASPS) is the largest organization of plastic surgeons in the world. Requirements for membership include certification by the American Board of Plastic Surgery.

As the umbrella organization for the specialty, ASPS represents 97 percent of 5,000 of the board-certified surgeons practicing in the United States and Canada. It serves as the primary educational resource for plastic surgeons and as their voice on socioeconomic issues. ASPS is recognized by the American Medical Association (AMA), the American College of Surgeons (ACS) and other organizations of specialty societies.

Definitions:
Abdominoplasty is defined as a surgical procedure that tightens a lax anterior abdominal wall and removes excess abdominal skin. It may be reconstructive or cosmetic.

Cosmetic and Reconstructive Surgery:
For reference, the following definition of cosmetic and reconstructive surgery was adopted by the American Medical Association, June 1989:

Cosmetic surgery is performed to reshape normal structures of the body in order to improve the patient's appearance and self-esteem.

Reconstructive surgery is performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors or disease. It is generally performed to improve function but may also be done to approximate a normal appearance.

Indications:
Abdominoplasty is considered reconstructive when performed to correct or relieve structural defects of the abdominal wall (ICD-9: 701.8/708.9) and/or chronic low back pain (ICD-9: 724.1) due to functional incompetence of the anterior abdominal wall. These conditions may be caused by:

1. Permanent overstretching of the anterior abdominal wall following one or more pregnancies; (ICD-9: 701.8.701.9).

2. Permanent overstretching (with or without diastasis recti (ICD-9: 928.84) of the anterior abdominal wall with a large or long abdominal panniculus (ICD-9: 278.1) following weight loss in the treatment of morbid obesity and resulting in the uncontrollable intertrigo (crease dermatitis, ICD-9: 692.9) and/or difficult ambulation (ICD-9 724.8).

3. Trauma or surgery to the anterior wall of the abdomen resulting in loss of muscle of fascial integrity or pain from scar contracture (ICD-9: 709.2).

4. Abdominal hernia following previous abdominal surgery (ICD-9: 553.201, 553.21).

Occasionally other hernias not related to previous surgery are present and corrected at the time of the abdominoplasty. They include umbilical hernia (ICD-9: 553.10) and epigastric hernia (ICD-9: 553.29).

It should be noted that there is a close relationship between abdominoplasty and another operation called panniculectomy. Panniculectomy is performed to relieve the massive apron of fat and is considered purely functional and therefore should be covered by the patient's insurance policy. It is done to relieve uncontrolled intertriginous dermatitis, difficulty in walking and occasionally actual skin necrosis.

Abdominal dermolipectomy has been performed since the turn of the century. In the United States, H.A. Kelly called attention to this procedure and its positive outcomes (weight reduction, personal comfort, convenience and comfort in dressing, better pose in standing and walking, increased activity and greater ease in hygiene) in his 1910 publication.

The anterolateral abdominal wall is largely muscular and aponeurotic with overlying subcutaneous tissue and skin. It consists of two strap muscles in front, (the rectus abdominis and phyraidalis), and three muscles anterolateral (the external oblique, internal oblique and transversus abdominis). The rectus sheath fuses medially with the linea alba and laterally with the fascia of the three anterolateral abdominal wall muscles. In turn, the internal oblique and the transverse abdomens fuse to the anterior and middle layers of the lumbar fascia (lumbodorsal fascia).

Abdominal wall pathophysiology concerns weakness or laxity of the abdominal wall musculature. This prevents maximum force general with contraction and weakens the support of the lumbar dorsal facia with resultant back pain. An excess of 10 pounds of adipose tissue in the abdominal wall adds 100 pounds of strain on the disks of the lower back by exaggeration of the normal "S" curve of the spine. Pregnancy may result in diastasis recti which decreases the efficiency of the abdominal wall musculature. Both genders may experience ventral hernias and weakness of the torso musculature, secondary to abdominal surgical incisions.

Procedures:
Reconstructive abdominoplasty can be a major operation. It may be performed on an inpatient hospital basis under general anesthesia or in an office surgical facility and may require a brief hospital stay. Reconstructive abdominoplasty often includes plication of the rectus muscles and sometimes the external oblique fascia. (CPT 15831). When indicated, specific hernia repairs (ventral hernia, CPT: 49581) may be performed at the same time. On occasion, it may be necessary to replace blood lost during the procedure.

Abdominoplasty may include suction lipoplasty of the upper and lateral abdomen to contour the reconstructed abdominal wall. It may be necessary to have assistance during surgery by another qualified reconstructive or general surgeon, especially if local hospital policy requires the presence of a board-certified general surgeon when the abdominal cavity is entered during repair of a ventral hernia.

Abdominoplasty (CPT: 15831), including correction of diastasis recti (ICD-9: 728.84) and excision of abdominal panniculus (ICD-9: 278.1), may also benefit a patient with low back pain (ICD-9: 724.2) and panniculitis (OCD-9: 724.8). The patient may also require ventral hernia repair (CPT: 49560; ICD-9: 55320, 553.21).

An abdominoplasty is usually performed under general anesthesia in an outpatient surgery center with an overnight stay or as inpatient surgery if the patient has particular risk factors. A lower transverse abdominal incision of varying length is made just above the pubis, usually extending out to each anterior superior iliac spine. An abdominal skin slap is elevated up to the costal margins, preserving attachment of the umbilicus to the linea alba. The diastasis recti or hernia is then repaired with nonabsorbable suture, reconstituting abdominal will integrity. The panniculus is then excised, and the remaining skin is sutured to the public area incision. The umbilicus is brought out through the skin flap at its appropriate is brought out through the skin flap at its appropriate level.

Cosmetic Abdominoplasty:
When an abdominoplasty is performed solely to the enhance a patient's appearance in the absence of any signs or symptoms of functional abnormalities, the procedure should be considered cosmetic in nature. It is the opinion of the ASPS that a cosmetic abdominoplasty is not a commendable procedure unless specified in the patient's policy.

Documentation:
When reconstructive abdominoplasty is preformed, the indications for surgery should be documented by the surgeon in the history and physical and reiterated in the operative note. Justification for abdominoplasty should be based on the probability of relieving clinical signs and symptoms associated with abdominal panniculus and diminished abdominal wall integrity, and include back pain, significant diastasis recti and/or hernia, recurrent intertriginous dermatitis, and poor hygiene.

Photographs are usually taken to document the preoperative condition and to aid the surgeon in planning surgery. In some cases, they may record physical signs; however, they do not substantiate symptoms and should only be used by third-party payer in conjunction with less subjective documentation. In circumstances where photographs may be useful to a third-party payer, the plastic surgeon should provide them. The patient, however, must sign a specific release, and confidentiality must be honored. It is the opinion of ASPS that a board-certified plastic surgeon should evaluate all submitted photographs.

Position Statement:
It is the position of the American Society of Plastic Surgeons that abdominoplasty, including repair of diastasis recti and panniculectomy, is reconstructive when performed to relieve specific clinical signs and symptoms related to abdominal wall weakness and panniculosis.

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2. Floros, C., Davis, P.K. B., "Complications and Long-tern Results Following Abdominoplasty: A Retrospective Study", British Journal Plastic Surgery, 44:190, 1991

3. Gracovetsky, S. Farfan, H., Helleur, C., "The Abdominal Mechanism," Spien 10:317, 1985

4. Hester, T., Roderick: Baird, Wilbur: Bostwick, John III: Nahai, Foad: Cukic, Juliana. "Abdominoplasty Combines with Other Major Surgical Procedures: Sage or Sorry?" Plastic and Reconstructive Surgery, 83:997, 1989

5. Kelly, H.A. "Excision of Fat of the Abdominal Wall - Lipectomy", Surgical Gynecology and Obstetrics, 10:229, 1910

6. Toranto, I. Richard. "The Relief of Low Back Pain with the WARP Abdominoplasty: A Preliminary Report", Plastic and Reconstructive Surgery, 85:545, 1990.

7. Toranto, I. Richard. "Resolution of Back Pain with the Wide Abdominal rectus Plication Abdominoplasty", Plastic and Reconstructive Surgery, 81:777, 1988.