This Medical Policy is provided for informational purposes only.

If Members have any questions about the medical necessity of a service or procedure, they should discuss the question with their Network Provider or call a member of our Customer Service Team.

MEDICAL POLICY USE DISCLAIMER

  1. Medical Policy is used by Blue Cross & Blue Shield of Mississippi, A Mutual Insurance Company ("BCBSMS") as one set of guidelines (among other sets of guidelines) to assist BCBSMS in making benefit coverage decisions. BCBSMS utilizes Medical Policy adopted by our Medical Policy Advisory Committee ("MPAC") which is supported by the Blue Cross and Blue Shield Association Medical Policy, research and development. Medical Policies are the property of BCBSMS and any use of Medical Policy not agreed to by BCBSMS is strictly prohibited. The use of Medical Policy for purposes related to the health care of a BCBSMS plan member is permitted and is not a violation of the proprietary rights of BCBSMS.
  2. These Medical Policies are based on scientifically meritorious evidence provided through research for a particular medical technology. Medical Policy is also based on data from peer-reviewed scientific literature, from criteria developed by specialty societies and from guidelines adopted by other health care organizations.
  3. These Medical Policies apply to members/subscribers who have health insurance through BCBSMS. This Medical Policy also applies to Members of a self-insured group health plan for which Blue Cross & Blue Shield of Mississippi provides claims administration and persons covered by a Medicare Supplement policy offered by BCBSMS. This Medical Policy does not apply to any other individuals. Medical Policies may differ for Federal employees covered under the Federal Employees Health Benefits Plan.
  4. In the event of any conflict between this Medical Policy and any benefit plan, Summary Plan Description or other coverage document, the benefit plan, Summary Plan Description or other coverage document will govern.
  5. Medical technology is rapidly changing and these Medical Policies are subject to change without notice. Also, please be aware that as a result of ongoing changes being made to Medical Policy, BCBSMS cannot and does not guarantee that these Medical Policies are current.

BCBSMS Medical Policies are Subject to the Following Restrictions


This Medical Policy is provided for informational purposes only.

If Members have any questions about the medical necessity of a service or procedure, they should discuss the question with their Network Provider or call a member of our Customer Service Team.

MEDICAL POLICY USE DISCLAIMER

  1. Medical Policy is used by Blue Cross & Blue Shield of Mississippi, A Mutual Insurance Company ("BCBSMS") as one set of guidelines (among other sets of guidelines) to assist BCBSMS in making benefit coverage decisions. BCBSMS utilizes Medical Policy adopted by our Medical Policy Advisory Committee ("MPAC") which is supported by the Blue Cross and Blue Shield Association Medical Policy, research and development. Medical Policies are the property of BCBSMS and any use of Medical Policy not agreed to by BCBSMS is strictly prohibited. The use of Medical Policy for purposes related to the health care of a BCBSMS plan member is permitted and is not a violation of the proprietary rights of BCBSMS.
  2. These Medical Policies are based on scientifically meritorious evidence provided through research for a particular medical technology. Medical Policy is also based on data from peer-reviewed scientific literature, from criteria developed by specialty societies and from guidelines adopted by other health care organizations.
  3. These Medical Policies apply to members/subscribers who have health insurance through BCBSMS. This Medical Policy also applies to members of a self-insured group health plan for which Blue Cross & Blue Shield of Mississippi provides claims administration and persons covered by a Medicare Supplement policy offered by BCBSMS. This Medical Policy does not apply to any other individuals. Medical Policies may differ for Federal employees covered under the Federal Employees Health Benefits Plan.
  4. In the event of any conflict between this Medical Policy and any benefit plan, Summary Plan Description or other coverage document, the benefit plan, Summary Plan Description or other coverage document will govern.
  5. Medical technology is rapidly changing and these Medical Policies are subject to change without notice. Also, please be aware that as a result of ongoing changes being made to Medical Policy, BCBSMS cannot and does not guarantee that these Medical Policies are current.

BCBSMS Medical Policies are Subject to the Following Restrictions


This Medical Policy is provided for informational purposes only.

If Members have any questions about the medical necessity of a service or procedure, they should discuss the question with their Network Provider or call a member of our Customer Service Team.

MEDICAL POLICY USE DISCLAIMER

  1. Medical Policy is used by Blue Cross & Blue Shield of Mississippi, A Mutual Insurance Company ("BCBSMS") as one set of guidelines (among other sets of guidelines) to assist BCBSMS in making benefit coverage decisions. BCBSMS utilizes Medical Policy adopted by our Medical Policy Advisory Committee ("MPAC") which is supported by the Blue Cross and Blue Shield Association Medical Policy, research and development. Medical Policies are the property of BCBSMS and any use of Medical Policy not agreed to by BCBSMS is strictly prohibited. The use of Medical Policy for purposes related to the health care of a BCBSMS plan member is permitted and is not a violation of the proprietary rights of BCBSMS.
  2. These Medical Policies are based on scientifically meritorious evidence provided through research for a particular medical technology. Medical Policy is also based on data from peer-reviewed scientific literature, from criteria developed by specialty societies and from guidelines adopted by other health care organizations.
  3. These Medical Policies apply to members/subscribers who have health insurance through BCBSMS. This Medical Policy also applies to members of a self-insured group health plan for which Blue Cross & Blue Shield of Mississippi provides claims administration and persons covered by a Medicare Supplement policy offered by BCBSMS. This Medical Policy does not apply to any other individuals. Medical Policies may differ for Federal employees covered under the Federal Employees Health Benefits Plan.
  4. In the event of any conflict between this Medical Policy and any benefit plan, Summary Plan Description or other coverage document, the benefit plan, Summary Plan Description or other coverage document will govern.
  5. Medical technology is rapidly changing and these Medical Policies are subject to change without notice. Also, please be aware that as a result of ongoing changes being made to Medical Policy, BCBSMS cannot and does not guarantee that these Medical Policies are current.

BCBSMS Medical Policies are Subject to the Following Restrictions

Medical Policy Search
Printer Friendly Version Wide Abdominoplasty Rectus Plication (WARP)

Wide Abdominoplasty Rectus Plication (WARP)

 

POLICY NUMBER

L.7.01.419

 

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.

Medically Necessary is defined as those services, treatments, procedures, equipment, drugs, devices, items or supplies furnished by a covered Provider that are required to identify or treat a Member's illness, injury or Nervous/Mental Conditions, and which Company determines are covered under this Benefit Plan based on the criteria as follows in A through D:

A.  consistent with the symptoms or diagnosis and treatment of the Member's condition, illness, or injury; and

B.  appropriate with regard to standards of good medical practice; and

C.  not solely for the convenience of the Member, his or her Provider; and

D.  the most appropriate supply or level of care which can safely be provided to Member. When applied to the care of an Inpatient, it further means that services for the Member's medical symptoms or conditions require that the services cannot be safely provided to the Member as an Outpatient.

For the definition of Medically Necessary, “standards of good medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary.

 

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.

09/01/2015: Code Reference section updated for ICD-10.

06/01/2016: Policy number added. Policy Guidelines updated to add medically necessary definition.

 

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)

HCPCS

  

ICD-9 Procedure

ICD-10 Procedure

86.83

Size reduction plastic operation

0J080ZZ, 0J083ZZ

Alteration of Abdomen Skin and Fascia (Abdominoplasty)

  0HB7XZZExcision of Abdomen Skin, External Approach

ICD-9 Diagnosis

ICD-10 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

K40.00 - K40.91

Inguinal hernia (code range)

K41.00 - K41.91

Femoral hernia (code range)

K42.0 - K42.9

Umbilical hernia (code range)

K43.0 - K43.9

Ventral hernia (code range)

K44.0 - K44.9

Diaphragmatic hernia (code range)

K45.0 - K45.8

Other specified abdominal hernia (code range)

K46.0 - K46.9

Unspecified abdominal hernia (code range)

 

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