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Notification Issue Date:
Medical Policy Bulletin
Title: Lipectomy and Liposuction
Policy #: 11.08.03j
This policy is applicable to the Company's commercial products only. Policies that are applicable to the Company's Medicare Advantage products are accessible via a separate Medicare Advantage policy database.
The Company makes decisions on coverage based on Policy Bulletins, benefit plan documents, and the member's medical history and condition. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable.
When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member's medical needs and condition. This decision is based on the member's current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.
This Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.
Coverage is subject to the terms, conditions, and limitations of the member's contract.
LIPECTOMY
When performed as a cosmetic service, lipectomy is a benefit contract exclusion for all products of the Company and is not eligible for reimbursement consideration. However, lipectomy is considered medically necessary and, therefore, covered for any of the following indications:
When provided during the removal of a lipoma for any of the following indications:
To relieve movement restriction and/or to correct functional impairment (e.g., lipomas of the palms, fingers, or feet that interfere with hand function or ambulation; lipomas of the tongue)
Deep lipomas present within or between muscles with compression on nerves or arteries (e.g., angiolipomas)
Lipomas suspected of a malignant process (e.g., documented associated adenopathy, recent fast growth, recent appearance of satellite masses)
When the procedure is provided in order to create symmetry in either the affected breast (ipsilateral) or unaffected breast (contralateral) when an individual is undergoing breast reconstruction after mastectomy
When the procedure is provided to the surrounding area of the breast during a medically necessary reduction mammoplasty
When the procedure is provided to correct severe asymmetry of the breast following a medically necessary reduction mammoplasty (e.g., due to further growth of the breast(s) or necrosis in one of the reduced breasts)
When the procedure is provided as a surgical option for the treatment of axillary hyperhidrosis when medical management (e.g., medications [Botox® (Botulinum Toxin Type A), anticholinergics, beta-blockers, benzodiazepines] and/or topical prescriptions) has failed
When performed as a cosmetic service, liposuction is a benefit contract exclusion for all products of the Company and is not eligible for reimbursement consideration. However, liposuction is considered medically necessary and, therefore, covered for any of the following indications:
When provided during the removal of a subcutaneous lipoma for either of the following indications:
To relieve movement restriction and/or to correct a functional impairment (e.g., lipomas of the palms, fingers or feet that interfere with hand function or ambulation; lipomas of the tongue)
Post-traumatic lipoma when both of the following are present:
Evidence of trauma and/or accident, at the site of the lipoma, of sufficient severity and within a time period consistent with the pathophysiology of lipoma development, to be reasonably considered the etiology of the lipoma
Documentation of such trauma and/or accident in the medical record prior to the appearance of the lipoma
When the procedure is provided to correct severe asymmetry of the breast following a medically necessary reduction mammoplasty (e.g., due to further growth of the breast[s] or necrosis in one of the reduced breasts)
EXPERIMENTAL/INVESTIGATIONAL
Liposuction for lymphedema is considered experimental/investigational and, therefore, not covered because the safety and/or effectiveness of this service cannot be established by review of the available published peer-reviewed literature.
Lipectomy and/or liposuction performed solely to change the appearance of any portion of the body, without improving the physiologic functioning of that portion of the body, is considered a cosmetic service. Services that are cosmetic are a benefit contract exclusion for all products of the Company. Therefore, they are not eligible for reimbursement consideration. This exclusion does not apply to post-mastectomy individuals solely in regard to their post-mastectomy, initial breast reconstruction status.
Services performed due to recent trauma and/or accident may be eligible for coverage when performed within a year of the event or within a year of the time at which the member's healing and/or skeletal and somatic maturation reasonably allows for repair and is intended to restore a member to a pre-trauma and/or pre-accident state, except when a specific benefit contract exclusion exists.
The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the health care professional's office, hospital, nursing home, home health agencies, therapies, and test reports.
The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.
All requests for lipectomy and/or liposuction for functional impairment require review by the Company and must include a letter of medical necessity and be supported by documentation. This documentation must include, but may not be limited to, photographs, medical records, and other health care professional reports.
BENEFIT APPLICATION
Subject to the terms and conditions of the applicable benefit contact, lipectomy and/or liposuction are covered under the medical benefits of the Company's products when the medical necessity criteria listed in this medical policy are met.
Services that are identified in this policy as experimental/investigational are not eligible for coverage or reimbursement by the Company.
Services that are cosmetic are a benefit contract exclusion for all products of the Company. Therefore, they are not eligible for reimbursement consideration.
Methods to remove fatty tissue include surgical excision and suction-assisted lipectomy (SAL) (a form of liposuction).
Lipectomy is a general term that describes the surgical removal of adipose (fatty) tissue. A lipectomy is performed in order to excise a lipoma (a fatty tumor) or to remove excess fatty tissue to reshape the contours of the face, neck, trunk, and extremities as a component of cosmetic surgery. Cosmetic services are those provided to improve an individual's physical appearance, from which no significant improvement in physiologic function can be expected. Emotional and/or psychological improvement alone does not constitute improvement in physiologic function.
Liposuction (suction-assisted lipectomy) is the aspiration of subcutaneous fat by the use of a suction method and various other techniques such as ultrasonic-assisted liposuction, laser-assisted liposuction, power -assisted liposuction, and water jet liposuction. Through small incisions, a suction cannula is placed into the fatty areas to be excised, and a vacuum is applied, allowing the fat to be drawn out of the body into collection containers.
Four types of liposuction techniques have been described based on the volume of infiltration or wetting solution injected: dry, wet, superwet, and tumescent. The essential difference between these techniques focuses on the amount of infusate into to the tissues and the resultant blood loss as a percentage of the aspirated fluid. For example, the tumescent liposuction technique involves infusion of fluid with epinephrine local anesthetic and other medications injected into the fatty layer before suctioning excess fat. Blood loss is approximately one percent of the aspirated volume.
Liposuction is frequently a component of cosmetic surgery. Liposuction aids in sculpting targeted areas of the body into a slimmer profile. The best candidates for liposuction are healthy individuals with relatively normal weight who have firm, elastic skin, yet have localized fat deposits that have been resistant to diet and/or exercise. In general, individuals with diminished skin elasticity may not achieve the same cosmetic results. Fat deposits may form beneath the chin, on the flanks, hips, abdomen, inner and outer thighs, knees, and around the calf of the lower leg. Liposuction is also used to sculpt and reduce the area around the waistline (i.e., love handles) and is frequently performed to remove fat in the abdominal area, neck, and face. Liposuction will not improve cellulite and is not intended as a substitute for overall weight loss.
In addition to using this procedure to contour the body, this technique is also used in the treatment of conditions such as axillary hyperhidrosis, lipodystrophy, and during breast reconstruction and lipoma removal. There are clinical circumstances when liposuction is used in conjunction with or as a means of performing certain surgical procedures. The treatment of axillary hyperhidrosis may include the removal of sweat glands with liposuction in order to reduce perspiration without impacting the body's overall ability to cool itself. After mastectomy, liposuction may be required during reconstructive procedures to create symmetry in projection, position, size, and shape of either the affected breast (ipsilateral) or unaffected (contralateral) breast. Additionally, the technique of liposuction is often used during a reduction mammoplasty because the use of small incisions during the procedure leads to less post-operative scarring and discomfort.
Liposuction has also been suggested as a treatment for individuals with chronic lymphedema (caused by an interruption in lymphatic drainage). Liposuction for lymphedema involves the surgical removal of excess subcutaneous fat tissue through several small incisions. It can be performed under general or regional anesthesia. Cannulas connected to a vacuum pump are inserted into small incisions and lymphedematous fat tissue is removed by vacuum aspiration. Current evidence on liposuction for chronic lymphedema is based on small numbers of individuals but suggests that there are no major safety concerns; however, the evidence on effectiveness is limited in quantity (NICE 2008).
LIPECTOMY AND LIPOSUCTION FOR LIPOMAS
A lipoma is a soft, slow-growing, fatty tumor that is most often situated between the skin and the underlying muscle layer. Histologically, a lipoma consists of a collection of adipocytes in multilobulated masses, sometimes enveloped by a fibrous capsule. It is almost always benign and typically presents in individuals who are 40 to 60 years of age as a round, movable, painless mass. Lipomas have been reported in the subcutaneous tissues of the neck, shoulders, or back, and, less frequently, in the face, scalp, hands, and feet. In rare instances, these tumors may also be found in deeper tissues such as the intramuscular septa, the abdominal organs, the oral cavity, the internal auditory canal, the cerebellopontine angle, and the thorax.
Lipomas may be associated with disorders such as the following:
Gardner's syndrome
Hereditary multiple lipomatosis
Adiposis dolorosa (rarely)
Variant lipomas are defined by cellular makeup and location and include angiolipomas, neomorphic lipomas, spindle cell lipomas, and adenolipomas. Variant lipomas must be distinguished from common benign lipomas. Additionally, a benign lipoma must be distinguished from liposarcoma (cancerous lipoma), which presents with a similar appearance but has far more serious consequences.
A lipoma can be removed by either surgical excision or liposuction. Surgical excision or lipectomy is the standard mode of therapy for lipomas to reduce the possibility of recurrence due to inadequate resection and the remote potential for malignant changes because liposuction alone will not allow for histopathological study. In addition, liposuction is sometimes used in the treatment of lipomas such as post-traumatic lipomas, where a link between soft tissue trauma and the formation of lipomas has been described. Available published peer-reviewed literature describes an advantage in the use of liposuction for the treatment of medium (4 to 10 centimeters) and large (greater than 10 centimeters) lipomas. Reportedly, there is no advantage to liposuction for the removal of small lipomas less than 4 centimeters because they can be expressed through small incisions.
American Society of Plastic Surgeons (ASPS). Liposuction. [ASPS Web site]. 2017. Available at: http://www.plasticsurgery.org/patients_consumers/procedures/Lipoplasty.cfm. Accessed February 20, 2017.
Bechara FG, Sand M, Sand D, et al. Surgical treatment of axillary hyperhidrosis: a study comparing liposuction cannulas with a suction-curettage cannula. Ann Plast Surg. 2006;56(6):654-657.
Benefit Contracts.
Bieniek A, Białynicki-Birula R, Baran W, et al. Surgical treatment of axillary hyperhidrosis with liposuction equipment: risks and benefits. Acta Dermatovenerol Croat. 2005;13(4):212-218.
Chalekson C. Liposuction techniques treatment & management. [Medscape Web site]. 08/06/2015. Available at: http://emedicine.medscape.com/article/1272642-treatment. Accessed February 20, 2017.
Chamosa M. Liposuction of the kneecap area. Plast Reconstr Surg. 1997;99(5):1433-1438.
Chung MT, Zimmermann AS, Paik KJ, Morrison SD, Hyun JS, Lo DD, et al. Isolation of Human Adipose-Derived Stromal Cells Using Laser-Assisted Liposuction and Their Therapeutic Potential in Regenerative Medicine. Stem Cells Transl Med. 2013;2(10):808-817.
Choi CW, Kim BJ, Moon Se, et al. Treatment of lipomas assisted with tumescent liposuction. J Euro Acad Dermatol Venereol. 2007;21(2):243-246.
Coleman WP 3rd. Noncosmetic applications of liposuction. J Dermatol Surg Oncol.1988;14(10):1085-1090.
Danilla S, Longton C, Valenzuela K, Cavada G, Norambuena H, Tabilo C, et al. Suction-assisted lipectomy fails to improve cardiovascular metabolic markers of disease: A meta-analysis. J Plast Reconstr Aesthet Surg.2013;66(11):1557-1563.
Fuente del Campo AF, Rojas Allegretti E, Fernandes Filho JA, Gordon CB. Liposuction: procedure for focal volume reduction and body contour remodeling. World J Surg. 1998;22(9):981-986.
Gabriel A. Large volume liposuction safety and indications. [Medscape Web site]. 01/14/2016. Available at: http://emedicine.medscape.com/article/1272958-overview. Accessed February 20, 2017.
Grazer FM. Body contouring. Introduction. Clin Plast Surg. 1996;23(4):511-528.
Haeck PC, Swanson JA, Gutowski KA, et al. Evidence-based patient safety advisory: liposuction. Plast Reconstr Surg.2009;124(4 Suppl):28S-44S. Also available online at: http://www.plasticsurgery.org/Documents/medical-professionals/health-policy/evidence-safety/Liposuction.pdf. Accessed February 20, 2017.
Heymans O, Castus P, Grandjean FX, Van Zele D. Liposuction: review of the techniques, innovations and applications. Acta Chir Belg. 2006;106(6):647-653.
Keck M, Kober J, Riedl O, Kitzinger HB, Wolf S, Stulnig TM, et al. Power assisted liposuction to obtain adipose-derived stem cells: Impact on viability and differentiation to adipocytes in comparison to manual aspiration. J Plast Reconstr Aesthet Surg. 2013.
Levesque AY, Daniels MA, Polynice A. Outpatient Lipoabdominoplasty: Review of the Literature and Practical Considerations for Safe Practice. Aesthet Surg J. 2013; 33(7):1021-1029.
Marks M, Marks C. Chapter 16: Trunk and Lower Extremity. Fundamentals of Plastic Surgery. Philadelphia, PA: W.B. Saunders Company; 1997: 330-331.
National Institute for Health and Care Excellence (NICE). Interventional procedure overview of liposuction for chronic lymphoedema. [NICE Web site]. July 2007. Available at:
https://www.nice.org.uk/guidance/ipg251/documents/liposuction-for-chronic-lymphoedema-interventional-procedures-overview2. Accessed February 20, 2017.
National Institute for Health and Care Excellence (NICE). Liposuction for chronic lymphoedema. [NICE Web site]. 02/27/2008. Available at:https://www.nice.org.uk/guidance/IPG251/chapter/1-guidance. Accessed February 20, 2017.
Nickloes TA, Sutphin DD, Radebold K. Lipomas. [Medscape Web site]. 06/19/2015. Available at: http://emedicine.medscape.com/article/191233-print. Accessed February 20, 2017.
Okoro SA, Barone C, et al. Breast reduction trend among plastic surgeons: a national survey. Plast Reconstr Surg. 2008;122(5):1312-20.
Pandya KA, Radke F. Benign skin lesions: lipomas, epidural inclusion cysts, muscle and nerve biopsies. Surg Clin N Am. 2009;89(3): 677-687.
Rossy KM. Lymphedema treatment & management. [Medscape Web site]. 02/16/2016. Available at: http://emedicine.medscape.com/article/1087313-treatment. Accessed February 20, 2017.
Schafer ME, Hicok KC, Mills DC, Cohen SR, Chao JJ. Acute adipocyte viability after third-generation ultrasound-assisted liposuction. Aesthet Surg J. 2013;33(5):698-704.
Schlereth T, Dieterich M, Birklein F. Hyperhidrosis—Causes and Treatment of Enhanced Sweating. Dtsch Arztebl Int. 2009;106(3): 32–37.
Sood J, Jayaraman L, Sethi N. Liposuction: Anaesthesia challenges. Indian Journal of Anaesthesia. 2011;55(3):220-227.
Spear SL, Burke JB, Forman D, et al. Experience with reduction mammaplasty following breast conservation surgery and radiation therapy. Plast Reconstr Surg. 1998;102(6):1913:6.
Venkataram J. Tumescent Liposuction: A Review. Journal of Cutaneous and Aesthetic Surgery. 2008;1(2):49-57.
Wilhelmi BJ, Blackwell SJ, Mancoll JS. Another indication for liposuction: small facial lipomas. Plast. Reconstr. Surg. 1999;103(7): 1864-1867.
Zuther JE. Lymphedema Management: The Comprehensive Guide for Practitioners. 2nd ed. New York, NY: Thieme; 2009.
Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.
The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.
In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.
The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.
CPT Procedure Code Number(s)
15832, 15833, 15834, 15835, 15836, 15837, 15838, 15839, 15876, 15877, 15878, 15879
Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.
Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.
ICD - 10 Procedure Code Number(s)
ICD -10 Diagnosis Code Number(s)
MEDICALLY NECESSARY
D17.0 Benign lipomatous neoplasm of skin and subcutaneous tissue of head, face and neck
D17.1 Benign lipomatous neoplasm of skin and subcutaneous tissue of trunk
D17.21 Benign lipomatous neoplasm of skin and subcutaneous tissue of right arm
D17.22 Benign lipomatous neoplasm of skin and subcutaneous tissue of left arm
D17.23 Benign lipomatous neoplasm of skin and subcutaneous tissue of right leg
D17.24 Benign lipomatous neoplasm of skin and subcutaneous tissue of left leg
D17.30 Benign lipomatous neoplasm of skin and subcutaneous tissue of unspecified sites
D17.39 Benign lipomatous neoplasm of skin and subcutaneous tissue of other sites
D17.72 Benign lipomatous neoplasm of other genitourinary organ
D17.79 Benign lipomatous neoplasm of other sites
L74.510 Primary focal hyperhidrosis, axilla
L74.52 Secondary focal hyperhidrosis
N62 Hypertrophy of breast
N64.89 Other specified disorders of breast
N65.0 Deformity of reconstructed breast
N65.1 Disproportion of reconstructed breast
R61 Generalized hyperhidrosis
I97.2 Postmastectomy lymphedema syndrome
I89.0 Lymphedema, not elsewhere classified
Q82.0 Hereditary lymphedema
HCPCS Level II Code Number(s)
Revenue Code Number(s)
Coding and Billing Requirements
&nbspPolicy: 07.06.01b: Complete Decongestive Therapy (CDT)
&nbspPolicy: 08.00.26v: Botulinum Toxin Agents
&nbspPolicy: 11.08.02h: Reduction Mammoplasty
&nbspPolicy: 11.08.06j: Panniculectomy, Abdominoplasty, and Other Excisions of Redundant Skin
&nbspPolicy: 11.08.12h: Surgery for Gynecomastia
&nbspPolicy: 11.08.15x: Reconstructive Breast Surgery
Policy History
Revisions from 11.08.03j:
08/29/2018 This policy has been reissued in accordance with the Company's annual review process.
Effective 10/05/2017 this policy has been updated to the new policy template format.
Version Effective Date: 05/19/2017
Version Issued Date: 05/19/2017
Version Reissued Date: 08/30/2018
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Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.