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Bilateral component separation/Panniculectomy

KBean2018

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Hello, I am looking for feedback regarding the below procedure? It is being denied with codes 15734,15847,15830. Any advice is appreciated. thank you

Bilateral component separation
extensive lysis of adhesions, PANNICULECTOMY, ventral hernia repair with mesh

Once the intra-abdominal contents were removed off of the peritoneum and posterior abdominal wall we assessed the remaining structures specifically the left side of her anterior abdominal wall. Obviously the rectus abdominis muscle is absent due to her previous TRAM flap. She also lost to the anterior rectus sheath on that side at the time of her previous infected mesh removal. All that remains on the left side was her skin, scar, and posterior rectus sheath attached to her hernia sac. Retracted laterally far to the left flank we are able to identify her external and internal oblique muscles. On the right side several centimeters off the midline we do identify a more normal anatomy including anterior and posterior rectus sheaths sandwiching a normal rectus muscle. Given the extent of her defect the decision is made to place a large synthetic mesh above the peritoneum in a retrorectus type of technique.
Once he is separated the layers of the abdominal wall to close the peritoneum and placed the mesh above it, I mobilized the right rectus muscle with the anterior sheath. A relaxing incision was made along the length of the right external oblique fascia. This allowed for movement of the right rectus muscle and anterior sheath towards the midline to cover the polypropylene mesh. On the left side a thin layer of scar was elevated off of the skin flap to provide coverage over the mesh as well. This was secured to the right muscle flap in the midline using a running 3-0 PDS suture as a unilateral component separation closure. The wound was then irrigated with normal saline. 2 15 French JP drains were placed. They were secured using 4-0 nylon suture. I assess the amount of redundancy of skin from her anterior abdominal wall. This was also done to excise the devascularized skin specifically from the left side of her abdomen after mobilizing the tissue to cover the mesh on the left side. More skin was resected from the left than the right for this reason. Once I was able to confirm that I could close the skin without significant tension I resected the excess. It was sent to pathology for examination. Hemostasis was confirmed with cautery. The skin was closed in layers using 3-0 Vicryl in the dermis and a running 4-0 strata fix Monocryl suture. Dermabond pernio was placed over the skin closure. An abominal binder was placed.
 
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