Print Wide Abdominoplasty Rectus Plication (WARP)

Wide Abdominoplasty Rectus Plication (WARP)

 

DESCRIPTION

Wide Abdominoplasty Rectus Plication (WARP) is a surgical procedure which tightens a lax anterior abdominal wall and removes excess abdominal skin. It may be reconstructive or cosmetic.

 

POLICY

Wide abdominoplasty rectus plication may be considered medically necessary when used to treat an abdominal wall hernia.  Documentation of a hernia requires clinical confirmation of the presence and size of the hernia by examination, ultrasound, or CT abdomen.

Wide abdominoplasty rectus plication is considered not medically necessary to treat reduction of panniculus,  intertrigo, or diastasis recti.

Cosmetic procedures are not covered.

 

POLICY EXCEPTIONS

None

 

POLICY GUIDELINES

The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.

 

POLICY HISTORY

11/2000: Approved by Medical Policy Advisory Committee (MPAC)

7/3/2001: Non-covered table added, ICD-9 diagnosis code 112.3, 278.1, 690.10, 695.89, 728.84 added non-covered codes

1/23/2002: Prior authorization deleted

5/10/2002: Type of Service and Place of Service deleted

11/19/2004: Code Reference section updated, CPT code 15831 description revised, ICD-9 diagnosis code range 550.00-553.9 listed separately, non-covered table deleted, ICD-9 diagnosis code 112.3, 278.1, 690.10, 695.89, 728.84 deleted non-covered codes

11/13/2006: Policy reviewed, no changes

1/3/2007: Code reference section updated per the 2007 CPT/HCPCS revisions

03/27/2014:  Policy statement re-written for clarity purposes. Intent unchanged.  Previously stated the following:  "This procedure will be considered medically necessary for a "true" hernia, but not medically necessary for size of panniculus, intertrigo or diastasis recti. Documentation of a "true hernia" requires confirmation of the presence and size by office notes, ultrasound or CT scan of the abdomen."  The policy statement regarding cosmetic procedures was changed from not medically necessary to not covered.

 

SOURCE(S)

Blue Cross Blue Shield of North Carolina

Aetna U.S. Healthcare

 

CODE REFERENCE

This may not be a comprehensive list of procedure codes applicable to this policy.

The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.

 Covered Codes

Code Number

Description

CPT-4

15830

Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy 

15847

Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen (eg, abdominoplasty) (includes umbilical transposition and fascial pilcation) (List separately in addition to code for primary procedure)

ICD-9 Procedure

86.83

Size reduction plastic operation

ICD-9 Diagnosis

550.00, 550.01, 550.02, 550.03, 550.10, 550.11, 550.12, 550.13, 550.90, 550.91, 550.92, 550.93, 551.00, 551.01, 551.02, 551.03, 551.1, 551.20, 551.21, 551.29, 551.3, 551.8, 551.9, 552.00, 552.01, 552.02, 552.03, 552.1, 552.20, 552.21, 552.29, 552.3, 552.8, 552.9, 553.00, 553.01, 553.02, 553.03, 553.1, 553.20, 553.21, 553.29, 553.3, 553.8, 553.9

Hernia code range

HCPCS

 

 

 

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