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14301 denied as not med necessary

  1. #1
    Question 14301 denied as not med necessary
    Clearnace Sale
    Patient defect after Mohs was determined by surgeon to require advancement flap 14301. Aetna requested notes on the case 2 times. Notes and photos were sent to support med nec. of 14301. Aetna denied the 14301 as not medically necessary. OrthoNet advised we should have billed complex repair. (Of note, Aetna paid the ASC claim for 14301.)
    Any suggestions on this one?


  2. #2
    I've found that insurance companies are beginning to scrutinize these adjacent tissue transfer codes for excessive use, and in my own work I have seen many cases of procedure notes that do not sufficiently document the work of an advancement flap. Per CPT instructions, the "undermining alone of adjacent tissues to achieve closure, without additional incisions, does not constitute adjacent tissue transfer, see complex repair codes 13100-13160." As I understand it, the operative note should document the work of fashioning the flap via new incisions after the completion of the lesion removal. It is not sufficient for the provider to just say that the wound was closed with a flap, or that the provider simply raised or undermined the wound in order to create a flap - that alone only meets the definition of a complex repair. But to be honest, I also don't think the insurance companies' reviewers completely understand this either, so if you and/or your physician feel that the documentation fully supports the flap code and is defensible, you may just need to escalate it to a higher level of appeal - perhaps have your provider draft a letter from a clinician's perspective that clearly spells out why the procedure meets the CPT definition.
    Last edited by thomas7331; 01-11-2019 at 03:14 PM.

  3. #3
    That's a great explanation. Thank you!

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