Coverage Policies

Use the index below to search for coverage information on specific medical conditions.

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Medical Providers: Payment for care or services is based on eligibility, medical necessity and available benefits at time of service and is subject to all contractual exclusions and limitations, including pre-existing conditions if applicable.

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QualChoice follows care guidelines published by MCG Health.

QualChoice reserves the right to alter, amend, change or supplement medical policies as needed. QualChoice reviews and authorizes services and substances. CPT and HCPCS codes are listed as a convenience and any absent, new or changed codes do not alter the intent of the policy.

INDEX:
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

Effective Date: 12/08/2010 Title: Abdominoplasty
Revision Date: Document: BI284:00
CPT Code(s): 15830, 15847, 15877
Public Statement

Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

 

Abdominoplasty, Panniculectomy and suction Lipectomy are generally not covered services.


Medical Statement
  1. Paniculectomy is considered medically necessary according to the following criteria:
    1. Panniculus hangs below the level of the pubis; and
    2. The medical records document that the panniculus causes chronic intertrigo (dermatitis occurring on opposed surfaces of the skin, skin irritation, infection or chafing) that consistently recurs over 3 months while receiving appropriate medical therapy, or remains refractory to appropriate medical therapy over a period of 3 months. and
    3. It has not resulted from non-covered surgical weight loss treatments.
      Paniculectomy is considered cosmetic when above criteria are not met.

 

Codes Used In This BI:

15830

Exc skin abd

15847

Exc skin abd add-on

15877

Suction assisted lipectomy


Limits
  1. Repair of a diastasis recti, defined as a thinning out of the anterior abdominal wall fascia, is not considered medically necessary because, according to the clinical literature, it does not represent a "true" hernia and is of no clinical significance.
  2. Abdominoplasty, suction lipectomy, or lipoabdominoplasty are considered cosmetic.

Background

In order to distinguish a ventral hernia repair from a purely cosmetic abdominoplasty, QualChoice requires documentation of the size of the hernia, whether the ventral hernia is reducible, whether the hernia is accompanied by pain or other symptoms, the extent of diastasis (separation) of rectus abdominus muscles, whether there is a defect (as opposed to mere thinning) of the abdominal fascia, and office notes indicating the presence and size of the fascial defect.

Abdominoplasty, known more commonly as a "tummy tuck," is a surgical procedure to remove excess skin and fat from the middle and lower abdomen and to tighten the muscles of the abdominal wall.  The procedure can improve cosmesis by reducing the protrusion of the abdomen.  However, abdominoplasty is considered by QualChoice to be cosmetic because it is not associated with functional improvements.


Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.
Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.
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