Question:
I have Blue Cross/Blue Shield Federal and am trying to get
approved for a panniculectomy. I have a double hernia that would be repaired at the same time. They keep denying me because my surgeon's "insurance lady" submits it under the code CPT 15831 which is the same code as for abdominplasty. I know they won't approve abdominplasty because it is considered cosmetic. She says there is no code for panniculectomy! I am at my wit's end trying to get this through to her!!!! I have even e mailed my surgeon. My hernia is so big I am going to have to have it fixed soon and want with all my heart to have the excess skin removed. Can anyone give me some advice on this? Or another code to use? Are these insurance codes secret or something? Why do you have to "know the secret code"??? I am very confused....help! — Mylou52 (posted on October 21, 2003)
October 22, 2003
Marilyn, have you tried calling a plastic surgeons office and asking for
the CPT code for panniculectomy?
— Cindy R.
October 22, 2003
Cindy, Thanks for responding. I was beginning to think no one read my
post! Yes, I did call and the "insurance lady" said it was the
same as the abdominplasty one. But they are different procedures and one
is considered cosmetic and one is considering "medical
necessity". Problem is BC/BS Federal cant/or won't differentiate
between the two. GRRRR. I have BC/BS of Illinois as a secondary and I
hope they will consider since BC/BS Federal is so dumb!!! I will fight
till the bitter end though as BC/BS Federal turned me down for my revision
when I had SLD too. They stink! I had to have my secondary AETNA cover
that and they didn't even argue. I am really upset with my insurance and I
am going to change to Special Agents Members
Benefits Assoc (SAMBA) as soon as open season is here in November. Anyone
know anything about them? They are just for employees of the Dept of
Justice. Thanks, Cindy.
— Mylou52
October 22, 2003
hey, I do coding for my job doing medical reviews. I'll look up the codes
for a plain panniculectomy. It IS a totally different code for an
abdominoplasty (tummy tuck). They aren't secret, just very confusing and
they change every stinkin' year!! Mostly the md offices have people fresh
out of high school doing precerts and have no medical background at all.
There is a process done to get the codes and if you don't know the medical
stuff, you end up wrong most of the time. We recode stuff the md's call to
us all the time. I'll check on this at work tomorrow, Thursday, 10/23/03
and get back to you tomorrow evening, okay?? karen
— Karen M.
October 22, 2003
I was approved for an "abdominoplasty" according to the woman who
works at my plastic surgeon. I asked two separate times if that meant the
surgeon would be doing muscle tightening. I was told twice yes it did, but
she didn't understand why something else wasn't approved because they both
sounded the same. I started think I bet the woman doesn't know the
difference between an abdominoplasty and a panniculectomy. So I had her
fax me a copy of the letters that my insurance sent to them. I got
approved to "remove excess skin/tissue, abdomen." The code for
that is what you said: 15831. I received a non-certification for
"abdomen surgery producer NEC." The clinical reviewer said that
"an abdominal wall reconstruction was not established as it would have
no functional improvement and would be cosmetic." The terms I'm
familiar with were not used. But I assume the abdominal wall
reconstruction is the muscle tightening that is done during abdominoplasty.
Oh and the code that I wasn't approved for is 22999. I have Blue Cross
insurance too. I would ask why you weren't approved under the code
submitted and try to fight that. Hope the information helps. Sherry
— sherry hedgecock
October 23, 2003
Thanks Karen, Cindy, and Sherry!!! You guys are so great and I will keep
trying to get this approved. If I am ever successful, I will try to help
others. We are all in this together and just knowing that you understand
makes me feel so good. After I talk to my insurance and others I feel so
frustrated and alone.....like no one cares. I will fight til I have no
other avenues to go down. Teena Adler is an inspiration to me. Her
profile is very helpful and I appreciate all of you. Thanks and God bless.
— Mylou52
October 24, 2003
Well folks, shut my mouth on this one!! Apparently now the codes for the
full abdominoplasty (tummy tuck) and the panniculectomy (loose skin
removal) are now the exact same code!!! 15831, there is only 1 different
code when they do liposuction at the same time, 15877. So, the insurance
company can now see the code and only approve which one they want to
apparently! That doesn't seem fair, but its the way it is. This was very
interesting to find out. The code books can only be purchased by
providers. They don't want the average joe getting them. They are pricey
to get. And very confusing to work getting the codes because there are so
many subset questions. At work we use a computer program that you answer
questions and it codes it for you. But I have used the book exclusively at
other jobs. Now, even though the ins co won't pay for the full tummy tuck,
because you are getting other surgery at the same time, you will have the
anesthesia and hospital charges covered, and if the panniculectomy is
covered, then you should only have to pay the surgeon's charges for doing
the extra procedure. It is still a cheap way to go to get it all done to
have an approved surgery at the same time. Good Luck. karen (open rny,
9/6/01, 297/146)
— Karen M.
October 29, 2003
I have an update on this. I called BC/BS and they told me the reason I am
being denied is because it was submitted as outpatient procedure. I am
having double hernia repair as well so I told the lady there and she said
to have the surgeon state the length of hospital stay and send in my 32
pages of documentation proving medical necessity and it would be reviewed.
She said federal employee insurers have instructed that if something is
sent in as outpatient then to NOT preauthorize it. If it is inpatient, it
will be considered! This could be helpful to all federal employees in
getting approved. Thank goodness she was nice enough to tell me the
"rules". This is very frustrating! Makes no sense to me that
they will cover a hospital stay but will NOT cover outpatient. Anybody
understand this?
— Mylou52
Click Here to Return