This edition of Guidelines for Medical Necessity Determination (Guidelines) identifies the clinical information that MassHealth needs to determine medical necessity for the excision of excessive skin and subcutaneous tissue from the abdomen, thigh, leg, hip, buttock, arm, forearm or hand, submental fat pad, or other area (described by CPT® codes 15830 – 15839). Panniculectomy is a surgical procedure to remove excessive skin and subcutaneous tissue from the abdomen. This excessive abdominal skin and subcutaneous tissue is called a panniculus. Panniculectomy does not include relocating the umbilicus or tightening of the abdominal muscles (abdominoplasty). Brachioplasty, also known as an arm lift, is a surgical procedure to remove excessive skin and subcutaneous tissue from the upper arm area. Thighplasty, also known as a thigh lift, is a surgical procedure to remove excessive skin and subcutaneous tissue from the thigh. These Guidelines are based on generally accepted standards of practice, review of the medical literature, and federal and state policies and laws applicable to Medicaid programs. These Guidelines do not address excision of excessive breast tissue, i.e., mastopexy (CPT 19316); reduction mammaplasty (CPT 19318); or mastectomy for gynecomastia (CPT 19300).
Providers should consult MassHealth regulations at 130 CMR 415.000: Acute Inpatient Hospital Services, 130 CMR 433.00: Physician Services, 130 CMR 410.000: Outpatient Hospital Services, and 130 CMR 450.000: Administrative and Billing Regulations; Subchapter 6 of the Physician Manual; and Subchapter 6 of the Acute Outpatient Hospital Manual for information about coverage, limitations, service conditions, and other prior-authorization (PA) requirements applicable to this service.
Providers serving members enrolled in a MassHealth-contracted accountable care partnership plan (ACPP), managed care organization (MCO), One Care Organization, Senior Care Organization (SCO), or Program of All-inclusive Care for the Elderly (PACE) should refer to the ACPP’s, MCO’s, One Care Organization’s, SCO’s, or PACE’s medical policies, respectively, for covered services.
MassHealth requires prior authorization (PA) for excision of excessive skin and subcutaneous tissue. MassHealth reviews requests for PA on the basis of medical necessity. If MassHealth approves the request, payment is still subject to all general conditions of MassHealth, including member eligibility, other insurance, and program restrictions.