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 Mental Health Disorders, 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 medical necessity, “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 L.7.01.419 added. Policy Guidelines updated to add medically necessary definition.

02/21/2023: Policy reviewed. Policy statements unchanged. Policy Guidelines updated to change "Nervous/Mental Conditions" to "Mental Health Disorders" and "Medically Necessary" to "medical necessity."

04/10/2024: Policy reviewed; no changes.

03/27/2025: Policy reviewed; no changes.

SOURCE(S)

1. Aetna U.S. Healthcare

2. Blue Cross Blue Shield of North Carolina

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

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