General Documentation Requirements for Panniculectomy, Excision of Excess Skin and Subcutaneous Tissue (Including Lipectomy) and Related Services
Checklist of prior authorization request (PAR) information to include:
- Stable weight loss with BMI less than 35 be obtained prior to authorization of coverage for panniculectomy surgery (when applicable)
- Description of the pannis and the underlying skin
- Description of conservative treatment undertaken and its results
- The medical records document (s) that the panniculus causes chronic intertrigo or candidiasis or tissue necrosis that consistently recurs over three months and is unresponsive to oral or topical medication (when applicable)
- Preop photograph (if requested)
- Copies of consultations (when applicable)
- Related operative report(s) (when applicable)
- Any other pertinent information such as medication, physical therapy, and other appropriate methods have been tried and proven unsuccessful
This checklist is not all inclusive; please submit any additional medical records that help support the medical necessity of the Hospital Outpatient Department service.
A facility or the beneficiary may submit the PAR and supplemental documentation via NGSConnex, esMD, fax or mail.
- NGSConnex
- YouTube instructional video on submitting through NGSConnex
- esMD: Content type 8.5
- Fax
- JK: 317-841-4530
- J6: 317-841-4528
- Mail
- National Government Services, Inc.
- Attention: Medical Review Prior Authorization Request
- P.O. Box 7108
- Indianapolis, IN 46207-7108
Provider Contact Center Inquiry Line:
- JK: 888-855-4356
- J6: 877-702-0990
Related Content:
- 42 Code of Federal Regulations 410
- Section 1842(P)(4) of The Social Security Act
- Centers for Medicare & Medicaid Services Internet-Only Manuals (IOMs) Publications:
- CMS IOM Publication 100-08, Chapter 3, Sections 3.6.2.2, 3.3.2.4, 3.6.2.2 and 3.2.3.8
- CMS IOM Publication 100-02, Chapter 15, Section 80.6.1
PAR decisions and the unique tracking numbers assigned for these services will be valid for 120 days. The decision date shall be counted as the first day of the 120 days. For example: if the PAR is affirmed on 1/1/2021, the PAR will be valid for dates of service through 4/30/2021. Otherwise, the provider will need to submit a new PAR.