ARCHIVED

Medical Policy

Policy Num:      07.001.040
Policy Name:    Post-Surgery Reconstructive Surgery Bariatric
Policy ID           [07.001.040]  [Ar / L / M+ / P+]  [0.00.00]

Last Review:    June 26, 2023
Next Review:    Policy Archived
 

ARCHIVED

Related Policies: None

Post-Surgery Reconstructive Surgery Bariatric
 

Summary

Morbid obesity is defined as an increase in body weight above an optimal level resulting in significant complications and comorbidities with a reduction in longevity. For example, morbid obesity has a significant impact on the cardiovascular risk factors, incidence of diabetes, obstructive sleep apnea, and various types of cancer (in men: colon, rectum and prostate and in women: breast, uterus and ovary, among others).

The first treatment for morbid obesity is diet with lifestyle modification. life, but this strategy only works in 5-10% who manage to reach and maintain the weight lost for more than three years. When conservative measures don't work there are surgical measures that can be considered in each particular case.

In 1991, the NIH established two levels for candidates for surgery based on the index of body mass (BMI):

1. Those with a BMI of 40kg/m2 or greater would be candidates and

2. Those with a BMI of 35kg/m2 with cardiopulmonary comorbidities or diabetes they would also be candidates.

After surgery and massive weight loss, some of these patients remain with deforming flaps, which are frequent areas of skin mycosis and infections and that make daily personal hygiene difficult. To these patients, many of whom have improved their diabetes, hypertension, apnea etc., they can be offered reconstructive surgery after bariatric surgery. The purpose of these procedures is focused on improving pre-existing diseases and improving the quality of life of the patient exclusively. It is not considered cosmetic surgery.

Objective

The objective of this review is to address medical indication for reconstructive surgery after bariatric surgery weight loss.

Policy Statement

Reconstructive procedures on the breasts, abdomen, back and lower back when you meet the following criteria established by SSS:

· Intractable skin infection documented by dermatologist.

· One year must have elapsed after bariatric surgery or loss of weight by another method.

· Weight must have been stable for at least 4 months before reconstructive surgery 

·  The tension and elasticity of the skin varies greatly, at least a loss of 70% of the total expected loss.

This should be calculated:

o Starting weight minus achieved weight, divided by starting weight minus weight ideal = > 70%

o The ideal weight is the one that corresponds to a BMI of 24 kg/m2 for that patient in particular.

· It is expected that in a tummy tuck they will remove four to six and a half pounds and in a breast reconstruction up to four and a half pounds.

· Hernia repair and abdominal diastasis recti repair are included in the price of abdominoplasties. If the plastic surgeon requests the intervention of another surgeon for the repair, the first will be responsible for the payment of this procedure to the other surgeon.

· All cases require prior authorization.

· The collection of deductibles or co-payments to the insured will not proceed.

· Surgical assistance will not be paid, nor can it be charged to the insured.

Policy Guidelines

All other indications for abdominoplasty, panniculectomy, and brachioplasty after massive weight loss are considered not medically necessary, including, but not limited to:

• Improving cosmesis in the absence of a functional impairment.

• Relieving neck or back pain, as there is no evidence that reduction of redundant skin and tissue results in less spinal stress or improved posture or alignment.

• Repairing a diastasis recti.

• Minimizing the risk of hernia formation or recurrence.

Endoscopic abdominoplasty or mini-abdominoplasty is not medically necessary for any reason. Panniculectomy when performed in conjunction with a primary abdominal surgical procedure will be considered as part of the primary surgery (e.g., incisional hernia repair) and not separately reimbursable.

• Note: All requests for panniculectomy in conjunction with repair of an incisional, umbilical, epigastric, or ventral hernia must be documented by the patient’s medical record and computed tomography scan recording the diameter of the fascial defect.

Benefit Application

BlueCard/National Account Issues

Benefits are determined by the group contract, member benefit booklet, and/or individual subscriber certificate in effect at the time services were rendered.  

Benefit products or negotiated coverages may have all or some of the services discussed in this medical policy excluded from their coverage.

Background

Obesity and its associated medical morbidities carry substantial health risk. Treatments for obesity, including bariatric surgery, often result in massive weight loss. Definitions of massive weight loss vary: 100 pounds (approximately 45.45 kg) or more; 50% or greater loss of excess weight; or greater than 100% above the person’s ideal body weight (Constantine, 2014; Manahan, 2006; Michaels, 2011). A sudden change in body mass index can lead to redundant skin and soft tissue with poor tone. Surplus skin and malpositioned adipose deposits result in musculoskeletal strain from increased tissue weight and can cause  functional limitation with walking, maintaining adequate hygiene, bowel and bladder habits, and sexual activity, as well as psychological issues associated with poor body image (Giordano, 2015).

Bariatric surgery is associated with various metabolic complications and deficiencies that can disturb wound healing and are not typically found in other conditions resulting in massive weight loss such as diet and exercise or post-pregnancy (Chandawarkar, 2006; Giordano, 2015)

Panniculectomy

The current medical evidence regarding panniculectomy consists mostly of individual case reports, review articles and a limited number of controlled trials. However, there is adequate clinical opinion to support the use of this procedure in some circumstances where an individual’s health is compromised.

Early studies by Matory (1994) and Vastine (1999) demonstrated a direct relationship between BMI and operative risk with abdominal surgery and abdominoplasty in obese individuals. In a retrospective cohort series of individuals who underwent post-bariatric panniculectomy (n=126), the only factor that independently predicted postoperative complications after panniculectomy was pre-panniculectomy BMI (Arthurs, 2007). Those with a BMI greater than 25 kg/m² were at nearly three times the risk of postoperative wound complications. Although those who experienced a plateau in weight loss at a BMI of 30-35 kg/m² did have the largest functional improvement from a panniculectomy, they also experienced the highest risk postoperatively. The average weight loss following bariatric surgery prior to panniculectomy was 116 ± 35 lbs. A limitation of this study was its retrospective design and sample size.

Acarturk (2004) compared the surgical outcomes of panniculectomy following bariatric surgery in another retrospective series of 123 participants (mean age 44.5 years). The outcomes of 21 participants with panniculectomy performed at the time of bariatric surgery were compared with the surgical outcomes of 102 participants who waited 17 ± 11 months to undergo panniculectomy. Overall, individuals who had panniculectomy simultaneously with bariatric surgery experienced more complications. Wound infections were 48% versus 16%; wound dehiscence 33% versus 13%; and there was a higher incidence (24% versus 0 %) of postoperative respiratory distress in individuals with the combined procedures. There were 3 postoperative deaths in the combined procedure cohort and none in the group that delayed panniculectomy until an average weight loss of 126 ± 59 lbs was achieved. The authors concluded that an initial period of substantial weight loss prior to the procedure results in a safer and more effective panniculectomy procedure.

The American Society of Plastic Surgeons (ASPS) Practice Parameter for Surgical Treatment of Skin Redundancy for Obese and Massive Weight Loss Patients (2007b) recommends that body contouring surgery, including panniculectomy, be performed only after an individual maintains a stable weight for 2 to 6 months. For individuals who are post-bariatric surgery, this is reported to occur 12-18 months after surgery when the BMI has reached the 25 kg/m² to 30 kg/m² range (Rubin, 2004). If performed prematurely, a potential exists for a second panniculus to develop once additional weight loss has occurred and the risks of postoperative complications are increased. Weight loss and BMI are important when considering panniculectomy and a significant amount of weight loss may not bring the BMI of an individual to less than 30 kg/m²; however, a panniculectomy may still be necessary (Arthurs, 2007). The American Society for Metabolic and Bariatric Surgery Consensus statement states weight loss can vary from about 25% to 70% of an individual’s excess body weight depending on the type of bariatric surgery that is performed (Buchwald, 2005).

A study by Zemlyak and colleagues (2012) reported on a retrospective review of individuals who had panniculectomy alone versus individuals who had panniculectomy and simultaneous ventral hernia repair. There were 143 participants in the panniculectomy/ventral hernia repair group and 42 participants in the panniculectomy group. The rates for incisional complications and interventions between the two groups were not statistically significant. However, after controlling for age, gender, BMI, subcutaneous use of talc, and intraoperative pulse-a-vac irrigation in the multivariate regression analysis, the group that had both panniculectomy and ventral hernia repair was more likely to develop wound cellulitis. The authors note that while panniculectomy with ventral hernia repair reduces the stress on the hernia repair and potentially decreases the recurrence rate, this potential advantage remains to be proven in robust comparative studies.

Fischer and colleagues (2014) conducted a large retrospective database analysis to assess the additional risk of ventral hernia repair (VHR) and panniculectomy (PAN) compared with hernia repair alone (n=55,537) using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) data sets. To account for potential selection bias given the non-randomized assignment of concurrent panniculectomy and the retrospective study design, propensity scores were used which yielded two comparable groups, VHR (n=1250) and VHR+PAN (n=1250). The study authors found that individuals who underwent the combined procedure were at significantly higher risk for wound complications (p<0.001), venous thromboembolism (p=0.044), reoperation (p<0.001) and overall medical morbidity (p<0.001). Two notable limitations of this study include that the ACS-NSQIP dataset only includes 30-day outcomes, precluding analysis of long-term differences in the two study groups. Secondly, the dataset did not include details on the type of panniculectomy skin resection or wound closure techniques, therefore propensity matching, and exploratory analysis of these potentially confounding variables was not possible. Nonetheless, at 30-day follow-up in this large retrospective cohort, outcomes of panniculectomy performed with a concurrent ventral hernia repair appear to result in a significant increase in morbidity compared to VHR alone.

Giordano and colleagues (2017) published a retrospective study based on a prospectively maintained database of all consecutive midline abdominal wall reconstructions for an abdominal wall hernia or oncologic defect performed at a single site from 2005-2015. Of 548 consecutive surgeries, 305 individuals (56%) underwent abdominal wall reconstruction alone and 243 (44%) underwent abdominal wall reconstruction with concurrent panniculectomy. The mean follow-up period was 30 months. Prior to propensity matching, individuals with the combined procedure also had a higher number of previous abdominal surgeries and a larger mean abdominal wall defect size. After propensity matching, there were significantly higher incidences of fat necrosis, and surgical site abscess but no significant difference in hernia recurrence at follow-up. Abdominal wall reconstruction with concurrent panniculectomy was associated with higher wound morbidity with no difference in hernia recurrence rates in follow-up.

Derickson (2018) published results from retrospective review of all post-bariatric surgery cases who underwent panniculectomy over a 10-year period (n=706). The overall rate of complication was 56%: dehiscence (24%), surgical site infection (22%), seroma (18%), and post-operative bleeding (5%). A total of 12% of individuals necessitated a return to the operating room. The study demonstrated a high morbidity for post-bariatric panniculectomy and authors noted higher BMI, higher ASA class, and the use of fleur-de-lis incision were particularly associated with worse outcomes.

Nag and colleagues (2021) published results from another systematic review conducted by ACS-NSQIP to determine the benefit, if any, of adding panniculectomy to gynecologic surgery in obese and morbidly obese individuals. In total, 296 individuals were identified from the NSQIP database who fit the search criteria. A statistically significant association was found between the concomitant procedures and adverse outcomes, including superficial infection, wound infection, pulmonary embolism, sepsis, return to operating room, length of operation and length of stay. Furthermore, there was no significant benefit identified across the studies.
Panniculectomy alone or with other abdominal surgical procedures, such as incisional or ventral hernia repair, or hysterectomy, is not clinically appropriate or an effective treatment of obesity. Recent meta-analyses have published mixed results of co-surgical procedures, but the studies lack documentation of a medical indication for removal of the pannus (Prodromidou, 2020; Rasmussen, 2017; Sosin, 2020). Although it has been suggested that the presence of a large overhanging panniculus may interfere with the surgery or compromise post-operative recovery, the presence of a pannus alone is not a medical condition which warrants surgical intervention. Removal of a pannus, for reasons other than those in the criteria for medical necessity is therefore considered cosmetic and not medically necessary.

Abdominoplasty

The literature addressing abdominoplasty and surgical repair of diastasis recti confirms the cosmetic benefits of these procedures. However, improvements in physical functioning, cessation of back pain, and other positive health outcomes have not been demonstrated. Carloni and colleagues conducted a systematic-review (2016) and confirmed that the quality of evidence surrounding abdominoplasty remains low and no standardization of surgical approaches has been established. Winocour (2015) reported results of a study which included 25,478 abdominoplasties and found high complication rates, compared to other cosmetic procedures, especially when abdominoplasty was combined with other procedures. Massenburg (2015) reported outcomes from 2946 abdominoplasties and found 8.5% of subjects were readmitted due to complications and 5% required revision surgery. Salari and colleagues (2021) conducted a systematic-review and meta-analysis to characterize the global prevalence of seroma following abdominoplasty and found the global prevalence following the procedure approaching 11% (95% CI, 9.3-3.6%). At this time, the evidence does not support abdominoplasty when done to remove excess abdominal skin or fat, with or without tightening lax anterior abdominal wall muscles, as an effective treatment for any medical condition, though it is an effective cosmetic procedure (ASPS Practice Parameter, 2007b).

Surgical procedures to correct diastasis recti are not effective for alleviating back pain or other non-cosmetic conditions. There is insufficient evidence to support the use of surgical procedures to correct diastasis recti for purposes other than cosmetic.

Similarly, the use of liposuction has been shown to produce cosmetic benefits in terms of appearance and body contour, however, liposuction has not been shown to be an effective treatment of obesity or other medical conditions and has been associated with significant complications, including death.

Rationale

Population Reference No. 1 

Panniculectomy after massive weight loss is clinically proven and, therefore, medically necessary when all of the above criteria are met, and there is photographic documentation (with member standing) of at least a Grade 2 panniculus that hangs to or below the level of the pubis. Abdominoplasty is clinically proven and, therefore, medically necessary when performed in conjunction with a panniculectomy that meets the above criteria. In this case abdominoplasty is considered part of the panniculectomy procedure and is not separately reimbursable.

Suplemental Information

References

1. National Institutes of Health. Consensus Development Conference Panel. Gastrointestinal surgery for severe obesity. Ann Intern Med 1991; 115(12):956-61.

2. TEC Special Report: The relationship between weight loss and changes in morbidity following bariatric surgery for morbid obesity. BCBSA TEC Assessment Program, 2003;18:1-25

3. Santry HP, Gillen DL, Lauderdale DS. Trends in bariatric surgery procedures. JAMA 2005, 294(15):1909-17.

4. MacLean LD, Rhode BM, Forse RA. Late results of vertical banded gastroplasty for morbid and super obesity. Surgery 1990; 107(1):20-7.

5. Willbanks OL. Long-term results of silicone elastomer ring vertical gastroplasty for the treatment of morbid obesity. Surgery 1987; 101(5):606-10.

6. Brolin RE. Results of obesity surgery. Gastroenterol Clin North Am 1987; 16(2):317-38.

7. Kolanowski J. Gastroplasty for morbid obesity: the internist’s view. Int J Obes Metab Disord 1995; 19 (suppl 3):S61-5.

8. Melissas J, Christodoulakis M, Spyridakis M et al. Disorders associated with clinically severe obesity: significant improvement after surgical weight reduction. South Med J 1998; 91(12):1143-8. Page 5 of 7

9. Hall JC, Watts JM, O'Brien PE et al. Gastric surgery for morbid obesity. The Adelaide Study. Ann Surg 1990; 211(4):419-27.

10.Sugerman HJ, Starkey JV, Birkenhauer R. A randomized prospective trial of gastric bypass versus vertical banded gastroplasty for morbid obesity and their effects on sweets versus non-sweets eaters. Ann Surg 1987; 205(6):613-24.

11.Griffen WO. Gastric bypass. In: Surgical Management of Morbid Obesity. Griffen WO, Printen KJ (eds.). New York: Marcel Dekker, Inc; 1987. pp. 27-45.

12.Pories WJ, Swanson MS, MacDonald KG et al. Who would have thought it? An operation proves to be the most effective therapy for adult-onset diabetes mellitus. Ann Surg 1995; 222(3):339-52.

13.Flickinger EG, Sinar DR, Swanson M. Gastric bypass. Gastroenterol Clin North Am 1987; 16(2):283-92.

14.Cowan GS, Buffington CK. Significant changes in blood pressure, glucose and lipids with gastric bypass surgery. World J Surg 1998; 22(9):987-92.

15.TEC Assessments 2005. Laparoscopic gastric bypass surgery for morbid obesity.

16.Rutledge R. The mini-gastric bypass: experience with the first 1,274 cases. Obes Surg 2001; 11(3):276-80.

17.Lap-Band® Adjustable Gastric Banding System, BioEnterics Corporation, Carpinteria, CA. Package insert.

18.TEC Assessment. Laparoscopic adjustable gastric banding for morbid obesity. TEC Assessment Program, 2006; volume 21, in press.

19.Moon Han S, Kim WW, Oh JH. Results of laparoscopic sleeve gastrectomy (LSG) at 1 year in morbidly obese Korean patients. Obes Surg 2005; 15(10):1469-75.

20.Langer FB, Bohdjalian A, Felberbauer FX et al. Does gastric dilatation limit the success of sleeve gastrectomy as sole operation for morbid obesity? Obes Surg 2006; 16(2):166-71.

21.Regan JP, Inabnet WB, Gagner M et al. Early experience with two-stage laparoscopic Roux-en-Y gastric bypass as an alternative in the super-super obese patient. Obes Surg 2003; 13(6):861-4.

22.Mognol P, Chosidow D, Marmuse JP. Laparoscopic sleeve gastrectomy as an initial bariatric procedure for high-risk patients: initial results in 10 patients. Obes Surg 2005; 15(7):1030-3. Page 6 of 7

23.Scopinaro N, Gianetta E, Adami GF et al. Biliopancreatic diversion for obesity at eighteen years. Surgery 1996; 119(3):261-8.

24.Slater GH, Ren CJ, Siegel N et al. Serum fat-soluble vitamin deficiency and abnormal calcium metabolism after malabsorptive bariatric surgery. J Gastrointest Surg 2004; 8(1):48-55.

25.Dolan K, Hatzifotis M, Newbury L et al. A clinical and nutritional comparison of biliopancreatic diversion with and without duodenal switch. Ann Surg 2004; 240(1):51-6.

26.Murr MM, Balsiger BM, Kennedy FP et al. Malabsorptive procedures for severe obesity: comparison of pancreaticobiliary bypass and very very long limb Roux-en[1]Y gastric bypass. J Gastrointest Surg 1999; 3(6):607-12.

27.Grimm IS, Schindler W, Haluszka O. Steatohepatitis and fatal hepatic failure after biliopancreatic diversion. Am J Gastrenterol 1992; 87(6):775-9.

28.Langdon DE, Leffingwell T, Rank D. Hepatic failure after biliopancreatic diversion. Am J Gastroenterol 1993; 88(2):321.

29.Marceau P, Hould FS, Simard S et al. Biliopancreatic diversion with duodenal switch. World J Surg 1998; 22(9):947-54.

30.Hess DS, Hess DW. Biliopancreatic diversion with a duodenal switch. Obes Surg 1998; 8(3):267-82.

31.Baltasar A, del Rio J, Escriva C et al. Preliminary results of the duodenal switch. Obes Surg 1997; 7(6):500-4.

32.Sugerman HJ, Kellum JM, DeMaria EJ. Conversion of proximal to distal gastric bypass for failed gastric bypass for superobesity. J Gastrointest Surg 1997; 1(6):517-25.

33. Inabnet WB, Quinn T, Gagner M et al. Laparoscopic Roux-en-Y gastric bypass in patients with BMI < 50: a prospective randomized trial comparing short and long limb lengths. Obes Surg 2005; 15(1):51-7.

34.Choban PS, Flancbaum L. The effect of Roux limb lengths on outcome after Roux-en-Y gastric bypass: a prospective, randomized clinical trial. Obes Surg 2002; 12(4):540-5.

35.Brolin RE, LaMarca LB, Kenler HA et al. Malabsorptive gastric bypass in patients with superobesity. J Gastrointest Surg 2002; 6(2):195-205.

36.MacLean LD, Rhode BM, Nohr CW. Long- or short-limb gastric bypass? J Gastrointest Surg 2001; 5(5):525-30.

37.Mason EE, Tang S, Renquist KE et al. A decade of change in obesity surgery. National Bariatric Surgery Registry (NBSR) Contributors. Obes Surg 1997; 7(3):189-97.

38.Nguyen NT, Paya M, Stevens CM. The relationship between hospital volume and outcome in bariatric surgery at academic medical centers. Ann Surg 2004, 240(4):586-94.

39.Liu JH, Zingmond D, Etzioni DA et al. Characterizing the performance and outcomes of obesity surgery in California. Am Surg 2003; 69(10):823-8.

40.Courcoulas A, Schuchert M, Gatti G et al. The relationship of surgeon and hospital volume to outcome after gastric bypass surgery in Pennsylvania: a 3-year summary. Surgery 2003; 134(4):613-21.

41.http://www.fda.gov/cdrh/pdf/p000008.html 42.Centers for Medicare and Medicaid Services. Decision memo for bariatric surgery for the treatment of morbid obesity (CAG-00250R). https://www.cms.hhs.gov/mcd/viewdecisionmemo.asp?id=160, accessed 3, 27/06.

43.Centers for Medicare and Medicaid Services. Minutes of 11/4/04 MCAC meeting for bariatric surgery. http://www.cms/hhs/gov/mcd/viewmcac.asp?where=index&mid=26, accessed 3/27/06.

Codes

Policy History