Description
Panniculectomy billed for cosmetic purposes will not be deemed medically necessary. In addition, panniculectomy billed at the same time as an open abdominal surgery, or if it is incidental to another procedure, is not separately coded per Coding Guidelines.
Affected Code(s)
15830, 15847
Applicable Policy References
1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer
2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits
3. 42 CFR §405.929- Post-Payment Review
4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
5. 42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor; and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party
6. 42 CFR §405.986- Good Cause for Reopening
7. 42 CFR §411.15 (h)- Particular services excluded from coverage
8. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
9. Medicare Benefit Policy Manual, Ch. 16- General Exclusions from Coverage, §120- Cosmetic Surgery
10. First Coast Service Option, Inc., LCD L38914- Cosmetic and Reconstructive Surgery; Effective 7/11/2021
11. Noridian Healthcare Solutions, LLC, LCD L35163- Plastic Surgery; Effective 10/01/2015; Revised 10/01/2019
12. Noridian Healthcare Solutions, LLC, LCD L37020- Plastic Surgery; Effective 10/10/2017; Revised 10/01/2019
13. Novitas Solutions, Inc., LCD L35090- Cosmetic and Reconstructive Surgery; Effective 10/01/2015; Revised 7/11/2021
14. Palmetto GBA L33428- Cosmetic and Reconstructive Surgery; Effective 10/01/2015; Revised 7/29/2021
15. Wisconsin Physician Service Corporation LCD L39051- Cosmetic and Reconstructive Surgery; Effective 11/14/2021; Revised 11/30/2023
16. First Coast Service Option, Inc., LCA A58573- Billing and Coding: Cosmetic and Reconstructive Surgery; Effective 7/11/2021
17. Noridian Healthcare Solutions, LLC, LCA A57221- Billing and Coding: Plastic Surgery; Effective 10/01/2019, Revised 10/01/2023
18. Noridian Healthcare Solutions, LLC, LCA A57222- Billing and Coding: Plastic Surgery; Effective 10/01/2019, Revised 10/01/2023
19. Novitas Solutions, Inc., LCA A56587- Billing and Coding: Cosmetic and Reconstructive Surgery; Effective 5/30/2019; Revised 7/11/2021
20. Palmetto GBA A56658- Billing and Coding: Cosmetic and Reconstructive Surgery; Effective 7/04/2019; Revised 4/15/2024
21. Wisconsin Physician Service Corporation LCA A58774- Billing and Coding: Cosmetic and Reconstructive Surgery; Effective 11/14/2021; Revised 8/31/2023
22. HCPCS Level II Codebook
23. ICD-10-CM Codebook