How does Medicare cover reconstruction?
Medicare covers reconstruction when medically necessary but reimbursement rates differ from commercial plans.
How does Medicaid vary?
Medicaid coverage varies by state and may have stricter authorization requirements.
What is ERISA?
ERISA governs many employer-sponsored health plans and sets rules for appeals and disputes.
What is recoupment?
Recoupment occurs when an insurer takes back money previously paid on a claim after an audit.
What triggers audits?
High-cost procedures, frequent modifier use, or unusual billing patterns can trigger review.
How are bilateral reconstructions reimbursed?
Payment depends on payer policy – some require modifier -50, while others require separate right and left side coding.
How are staged expander-to-implant procedures billed?
The tissue expander placement and later implant exchange are billed as separate procedures performed at different times.
How is acellular dermal matrix (ADM) billed?
ADM may be billed with a separate code when allowed by the payer, but some insurers bundle it into the primary reconstruction code.
What causes fat grafting denials?
Insurers may misclassify fat grafting as cosmetic unless documentation clearly links it to reconstructive necessity.
What is a medical policy?
A medical policy is an insurer’s internal guideline outlining criteria required for coverage of specific procedures.