• This page, MassHealth Guidelines for Medical Necessity Determination for Excision of Excessive Skin and Subcutaneous Tissue, is offered by
  • MassHealth

MassHealth Guidelines for Medical Necessity Determination for Excision of Excessive Skin and Subcutaneous Tissue

The MassHealth Guidelines for Medical Necessity Determination (Guidelines) are used by MassHealth's reviewing clinicians to determine the medical necessity of prior-authorization requests submitted by providers.

Table of Contents

Guidelines for Medical Necessity Determination for Excision of Excessive Skin and Subcutaneous Tissue

These Guidelines for Medical Necessity Determination (Guidelines) identify 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 433.000 and 450.000, and Subchapter 6 of the Physician Manual for information about coverage, limitations, service conditions, and prior authorization requirements.

Providers serving members enrolled in a MassHealth-contracted accountable care partnership plan (ACPP), managed care organization (MCO), integrated care organization (ICO), senior care organization (SCO), or program of all-inclusive care for the elderly (PACE) should refer to the ACPP’s, MCO’s, ICO’s, SCO’s or PACE’s medical policies for covered services.

MassHealth requires prior authorization for excision of excessive skin and subcutaneous tissue. MassHealth reviews requests for prior authorization 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.

Additional Resources for Guidelines for Medical Necessity Determination for Excision of Excessive Skin and Subcutaneous Tissue

Feedback