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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.
POLICYWide 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.
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.
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.
Blue Cross Blue Shield of North Carolina
Aetna U.S. Healthcare
CODE REFERENCEThis 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.