Prior authorization for plastics, derm, and wound care, from breast reconstruction to HBOT

Plastics, dermatology, and wound care cluster because they share reconstruction and tissue-work logic. A breast reconstruction PA shares documentation DNA with a panniculectomy PA. A Mohs closure shares elements with a wound-care skin substitute. And HBOT PA sits at the intersection of wound care, hyperbaric medicine, and hospital outpatient coding. This page walks all four.

Plastic and reconstructive surgery

Breast reconstruction after mastectomy is federally protected under WHCRA (Women's Health and Cancer Rights Act) but still PA'd for scheduling. Tissue expander placement (19357), implant exchange (19342), autologous reconstruction (19364 free flap, DIEP, TRAM codes 19367, 19369), and nipple reconstruction (19350) all require surgical documentation, mastectomy pathology, and sometimes symmetry procedures on the contralateral breast. Flap-based reconstruction requires additional imaging (CTA for DIEP).

Panniculectomy (15830) after bariatric surgery or massive weight loss is the highest-scrutiny reconstructive PA. Payers want documented weight stability for 18-24 months, intertrigo with failed medical management, recurring skin infections, or functional limitation. Cosmetic distinction is strict, and denials usually cite insufficient documentation of functional impairment. Abdominoplasty (15847) is rarely covered by insurance outside the WHCRA context.

Gender-affirming surgery (top and bottom surgery, 19325 augmentation for trans women, 55970 gender-affirming genital surgery codes) has expanded coverage in commercial plans following CMS guidance and state mandates. PA typically requires letters of support from mental health professionals, hormone therapy documentation, and specialist consultation.

Dermatology: biologics, excisions, phototherapy

Dermatology PA is heavy on biologics. Dupixent (dupilumab, J2182) for atopic dermatitis, Humira and biosimilars for psoriasis, Skyrizi (risankizumab, J2327), Tremfya (guselkumab, J1628), Cosentyx (secukinumab, J3245), Taltz (ixekizumab, J1834), and Ilumya (tildrakizumab, Q5121) all require step therapy documentation (typically failed phototherapy, topical steroids, methotrexate, or cyclosporine), severity scoring (PASI for psoriasis, EASI and IGA for atopic derm), and affected body surface area.

Surgical derm (excision codes 11400-11646, Mohs 17311-17315, complex closure codes 13100-13160, adjacent tissue transfer 14020-14061) is PA'd inconsistently. Lesion excision rarely requires PA if benign; malignancy biopsies drive the trigger for PA on excision. Phototherapy (96910, 96912) and photodynamic therapy (96567) require failed topical therapy documentation.

Mohs surgery

Mohs micrographic surgery (17311 first stage head and neck, 17313 first stage trunk, 17312 additional stages) is one of the most audited PA categories because of appropriate-use criteria scrutiny. Payers increasingly require documentation of lesion location, histology from the biopsy, and an AUC score supporting Mohs over standard excision. The AAD Appropriate Use Criteria are the benchmark most payers reference. Closure codes (13101, 13132, 14040, flap codes 15574-15574) add their own PA layer on complex closures.

Wound care and skin substitutes

Wound care PA is where the complexity concentrates. Skin substitute application (15271-15278 for external application, depending on graft size and location) has an extensive CMS LCD landscape in 2026 following the skin-substitute LCD consolidation. Commercial plans follow similar logic: proof the wound has not healed with 30-60 days of standard wound care, measurements showing insufficient progress, debridement documentation, and appropriate product selection from the payer's covered list. The covered product list varies widely: Apligraf, Dermagraft, EpiFix, Grafix, PriMatrix, MatriStem, TheraSkin, Affinity, and dozens more have plan-specific coverage.

Negative-pressure wound therapy (NPWT) rental (E2402) requires wound type, size, and progress documentation. Cellular and tissue-based products for diabetic foot ulcers and venous leg ulcers have separate coverage policies and documentation requirements.

Hyperbaric oxygen (HBOT)

HBOT (99183) is covered by Medicare under NCD 20.29 for 15 specific indications including diabetic foot ulcer (Wagner grade 3 or higher with specific failure criteria), osteoradionecrosis, chronic refractory osteomyelitis, acute traumatic ischemia, compromised skin grafts and flaps, and gas gangrene. Commercial plans typically follow the CMS NCD. PA requires the indication, wound staging, failed conventional therapy documentation, and often weekly recertification during a course of therapy.

Payer rules for plastics and wound

Plastic surgery PA usually stays with the medical plan directly. Derm biologics route through the PBM (CVS Caremark, OptumRx, Express Scripts) with step therapy enforcement. Wound care and HBOT at hospital outpatient or wound-care centers often require both a medical PA for the procedure and a facility-side process for HBOT chamber scheduling. See the full payer map at commercial payers and the government-payer detail including Medicare NCD 20.29 at Medicare, Medicaid, and government payer PA.

Plastics, derm, and wound EHRs

• Plastics: Nextech Plastic Surgery, PatientNow, Aesthetic Record, Symplast, ModMed Plastic.
• Dermatology: ModMed EMA Derm, Nextech Derm, PracticeStudio, eClinicalDerm, EZDerm.
• Wound care: Net Health Wound Expert, Intellicure, PointClickCare SNF wound modules, Casamba (Net Health).
• See outpatient EHRs and post-acute EHRs.

How Flexbone handles plastics and wound PA

Plastics and derm are biologic-and-procedure practices where PA splits between PBM (drug) and medical (procedure). Wound and HBOT are cadence-driven where weekly recertification dominates. Flexbone runs the two patterns as separate workflows inside one platform, with calendar-driven recert for HBOT and skin substitute. See PA workflow and the platform.