Recent authorization denials for skin flaps
Hello! Looking for guidance on recent insurance denials for skin flaps. Are other centers experiencing authorization denials for skin flaps and is there a resolution to obtain authorization? 2 patient experiences are listed below. We still have the appeal opportunity with Humana. Thank you!

1) Patient #1 with Humana
a. denying with patient history: 9/25/25 “Excision Preparation and Repair of Left Ala Defect 5x3cm ,Paramedian Forehead Flap 9x2cm Left Side, Left Auricular Cartilage Graft. There was concern for tissue compromise of the flap at the end of the case and the flap was slightly pale.” Humana states “does not meet the requirements for approval”. They note that there was Moh’s excision with flap placement, flap not healing properly, and doctor ordering treatment for healing. Humana continues to state they follow Medicare requirements and patient records show a “non-healing surgical wound. HBOT is not the primary treatment for this type of wound. The request is not medically necessary.” They based the decision on NCD 20.29 and Humana Medical Coverage Policies – HBOT Medicare Advantage. Our center used T86.821 for the code.
b. From Wound Reference’s page on Compromised Skin Grafts and Flaps, it states under medical necessity: “This topic discusses Compromised Skin Flaps and Grafts, including reimplantation of digits or extremities. This condition meets coverage indications per the National Coverage Determination (NCD) 20.29”

2) Patient #2 with Blue Care Network HMO Commercial
a. Final denial after 1st appeal and 2nd appeal both denied. Patient underwent local flap advancement with umbilicoplasty on 8/28/25. She was seen by her surgeon for follow up on 9/3/25. Darkening of the incision edges was found. Surgeon recommending patient undergo HBOT due to risk of flap breakdown or incision dehiscence, as well as to optimize healing of the compromised abdominal flap and for improvement in healing of the lower abdominal incision.
b. BCN states they cannot authorize HBOT due to: there is “no indication that you have a treatable condition such as skin grafts”, wounds that don’t meet policy criteria are considered experimental and investigational, and “only services that are considered medically necessary are payable”
i. The BCN Medical Policy includes:
1. FDA approval for “Skin graft flap at risk of tissue death”.
2. Inclusionary and Exclusionary Guidelines, states inclusions: “Preparation and preservation of compromised skin grafts (not for primary management of wounds)”
3. 2023 Input from physician specialty societies and academic medical centers: For individuals with acute surgical or traumatic wounds and compromised skin grafts or flaps who receive systemic HBOT, clinical input supports this use provides a clinically meaningful improvement in net health outcomes and indicates this use is consistent with generally accepted medical practice.
Oct 6, 2025 by Sarah Karson, RN, BSN
1 replies
Kim Simonson
RN-BC, ACHRN, CWS, FACCWS

Hi Sarah,

 

I’m sorry you’ve encountered recent denials for skin flaps and grafts. I’m not aware of a broader increase in denials for this indication, but it’s important to review each payer’s HBOT eligibility requirements before initiating treatment and to ensure thorough documentation. This includes past history, type and date of surgery, HBOT workup, HBOT orders, and clear documentation addressing each eligibility criterion for the indication of compromised flaps and grafts.  WoundReference has a HBOT Request Checklist for Compromised Flaps and Grafts based on CMS NCD 20.29 for this indication that can help.

 

It’s helpful when the HBOT medical necessity workup itself uses the terminology outlined in the payer’s eligibility requirements. For example: explicitly state that the patient’s procedure was a graft (or flap if applicable), list theT86.821 code first, clearly document that the incision line is in the process of failing or failed, and describe the specific clinical findings (e.g., ischemic, dusky, pale).  Use as many descriptors as possible to paint the picture of a failing flap/graft (the word “ischemic” is usually included).  Include a wound picture.  This precision both supports medical necessity and strengthens any future appeal. 


I recommend reviewing the WoundReference topic, “Compromised Skin Grafts and Flaps” as a strong reference point.  You may also find WoundReference's topic ,“Medicare Billing Protocol - Appeal of Claim” a helpful resource for strategies on handling denials and appeals.  Remember to include complete documentation with all appeal submissions as well.


Continue to appeal the cases which you have outlined.  It may be necessary to appeal up to the state level.  Hopefully, these denials will be overturned for you.  

 

Kim

Oct 7, 2025
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