Policy challenge to advocacy victory: How ASPS helped reverse Aetna's reconstructive surgery bundling policy

Changes to payer policies can have significant consequences for plastic surgeons, their practices and, most importantly, their patients. A recent decision by Aetna involving adjacent tissue transfer and reconstructive flap procedures illustrates both the potential impact of these policies and the power of coordinated advocacy to bring about meaningful change.

Aetna implemented a claims edit on July 1 that bundled payment for adjacent tissue transfer procedures (CPT codes 14000-14302) and reconstructive flap procedures (CPT codes 15733-15738) when performed by another surgeon on the same date as certain breast procedures (CPT codes 19300-19396) or digestive system procedures (CPT codes 40490-49999). Under the policy, these reconstructive services could be denied as incidental to the primary procedure. ASPS strongly opposed the policy because it didn't appropriately distinguish routine wound closure from medically necessary reconstructive procedures requiring separate work, expertise and clinical judgment. Although individual code combinations may be subject to specific coding edits, a broad policy bundling entire families of reconstructive codes is inconsistent with established CPT coding principles and doesn't reflect the clinical realities of complex reconstruction.

Serious concerns

Adjacent tissue transfers and reconstructive flaps aren't simply incidental closures. These procedures can require separate incisions, elevation and mobilization of tissue, transfer and inset of vascularized tissue, closure of the donor site, independent preoperative planning and postoperative management by the reconstructive surgeon.

These services are used selectively to address significant defects resulting from cancer resection, trauma and other conditions. They may be necessary to restore breast contour following breast-conserving surgery, cover exposed structures after extensive cancer resection, reconstruct perineal defects following colorectal surgery or restore abdominal wall integrity during complex ventral hernia repair.

By denying separate reimbursement for these services, the Aetna policy had the potential to discourage reconstructive surgeons from participating in a patient's care or require reconstruction to be delayed and performed during a separate operation. This could expose patients to additional anesthesia, longer hospital stays, an increased risk of infection and wound-healing complications, delays in treatment and greater physical and emotional burdens.

ASPS takes action

Before the policy's scheduled implementation, ASPS submitted a formal letter to Aetna on May 12 outlining the Society's clinical, coding and patient-access concerns. The letter explained that adjacent tissue transfers and reconstructive flaps represent distinct services that extend well beyond the routine closure included in the primary procedure. ASPS urged Aetna to rescind or revise the policy and recommended targeted claims review and auditing as a more appropriate way to address potential improper billing.

Despite these concerns, Aetna implemented the policy on July 1 without responding to ASPS. The Society continued its advocacy and submitted a second, more direct letter on Aug. 26 requesting immediate reconsideration. That letter further detailed the policy's potential impact on access to reconstructive surgeons, multidisciplinary care and patients requiring timely reconstruction.

On Sept. 3, Aetna notified ASPS that, after reviewing the clinical scenarios presented by the Society, it would discontinue the claims edit. Aetna terminated the rule on the evening of Sept. 4, retroactive to its July 1 effective date.

The reversal represents an important advocacy victory for plastic surgeons and their patients. It also demonstrates the value of providing payers with clear coding analysis, compelling clinical examples and a detailed explanation of how reimbursement policies can affect the delivery of patient care.

Practices should review claims affected by the edit between July 1 and Sept. 4 and contact Aetna regarding the handling of any prior denials. Because Aetna's response didn't specify whether affected claims would be reprocessed automatically, practices should monitor claims carefully and follow up directly when necessary.

First line of defense

This outcome also highlights the essential role of ASPS members and their coding and billing teams in identifying problematic payer policies. Physicians, coders and billers are often the first to see a new policy announcement, unexpected claims edit or a pattern of denials that may signal a broader reimbursement issue.

ASPS can advocate most effectively when members promptly share what they're experiencing. When reporting a potential issue, practices should provide as much information as possible, including:

• The payer and specific health plan involved
• A copy or link to the applicable policy or provider bulletin
• The affected CPT codes and services
• The effective date of the policy or edit
• The denial reason, explanation of benefits or remittance advice
• Information about any appeal or reconsideration and its outcome
• Whether the issue appears to affect a single claim or reflects a broader pattern

Note: Patient information should be removed from any materials submitted to ASPS.

A single report can help identify an emerging issue, while reports from multiple practices can demonstrate the scope and impact of a policy. This information allows ASPS to investigate, engage payer leadership and advocate with the clinical and coding evidence needed to support meaningful change.

The reversal of Aetna's policy shows what can be accomplished when ASPS, its members and practice teams work together. Members and their coders and billers are encouraged to remain vigilant and report concerning payer policies, reimbursement changes and denial trends to eadler@plasticsurgery.org. By sharing these issues early, we can work together to protect appropriate reimbursement, preserve access to reconstructive care and advocate on behalf of the specialty and our patients.