Removing excess abdominal skin folds is a common surgical procedure. However‚ the medical necessity for the procedure is not always clear. The medical necessity guidelines for this procedure require physicians to carefully review clinical information and determine if the procedure is medically necessary. Listed below are some of the key factors to consider when determining whether a procedure is medically necessary.
15830
We recently encountered an insurance denial of 15830 for removal of abdominal skin folds. This was a case where a patient had a history of major gastrointestinal problems and had undergone a laparoscopic colectomy and gastric pacemaker. After these procedures‚ the patient lost a significant amount of weight and developed ongoing rashes. She also complained of back pain.
The procedure involves surgically removing excess abdominal skin folds and fat. This procedure is often performed as a cosmesthetic procedure. The presence of a massive overhanging apron of fat and skin can result in chronic skin conditions in the abdominal folds‚ including cellulitis‚ ulcerations‚ tissue necrosis‚ and intertrigo. These conditions can interfere with daily activities. Treatment of these conditions may include topical steroids‚ antifungals‚ or systemic antibiotics.
Recurrent documented rashes not responding to conventional treatment
In some instances‚ the rashes may be a result of an infection. These infections are called tinea versicolor or pityriasis versicolor. These infections can be diagnosed by KOH examination. Although these infections are not serious‚ many patients desire treatment for the cosmetic reasons. If the rash is chronic‚ treatment options can include oral antibiotics or topical tretinoin. Other treatments may include a salicylic acid-containing skin moisturizer.
Guidelines for medical necessity determination
Medical necessity is a key consideration in the decision-making process for any cosmetic surgery. Abdominal skin fold removal is a common procedure that requires clinical documentation to establish medical necessity. This procedure involves the removal of excess skin and subcutaneous tissue from the abdominal area. In some cases‚ it may also involve removal of a submental fat pad.
Although there are several factors that influence medical necessity‚ a reasonable standard of proof is convincing evidence of chronic functional problems and the failure of conservative treatments. These criteria are generally not met in this case‚ as the patient did not have a medical record that documents his skin fold or has photographs that demonstrate its presence.
