Medical Policy Update

New Medical Policy

Update to previous notice
Medical Policy: New Policy III.274 Tissue Transfer (Flaps)

Effective Date: 5/1/2026
Preauthorization Required: Yes

Starting 5/1/2026 Interqual Criteria will be utilized for tissue transfer (flap).
Codes:
14000 - Adjacent tissue transfer or rearrangement, trunk; defect 10 sq cm or less
14001 - Adjacent tissue transfer or rearrangement, trunk; defect 10.1 sq cm to 30.0 sq cm
14020 - Adjacent tissue transfer or rearrangement, scalp, arms and/or legs; defect 10 sq cm or less
14021 - Adjacent tissue transfer or rearrangement, scalp, arms and/or legs; defect 10.1 sq cm to 30.0 sq cm
14040 - Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10 sq cm or less
14041 - Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10.1 sq cm to 30.0 sq cm
14060 - Adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips; defect 10 sq cm or less
14061 - Adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips; defect 10.1 sq cm to 30.0 sq cm
14301 - Adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm
14302 - Adjacent tissue transfer or rearrangement, any area; each additional 30.0 sq cm, or part thereof (List separately in addition to code for primary procedure)
14350 - Filleted finger or toe flap, including preparation of recipient site
15570 - Formation of direct or tubed pedicle, with or without transfer; trunk
15572 - Formation of direct or tubed pedicle, with or without transfer; scalp, arms, or legs
15574 - Formation of direct or tubed pedicle, with or without transfer; forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands or feet
15576 - Formation of direct or tubed pedicle, with or without transfer; eyelids, nose, ears, lips, or intraoral
15600 - Delay of flap or sectioning of flap (division and inset); at trunk
15610 - Delay of flap or sectioning of flap (division and inset); at scalp, arms, or legs
15620 - Delay of flap or sectioning of flap (division and inset); at forehead, cheeks, chin, neck, axillae, genitalia, hands, or feet
15630 - Delay of flap or sectioning of flap (division and inset); at eyelids, nose, ears, or lips
15650 - Transfer, intermediate, of any pedicle flap (eg, abdomen to wrist, Walking tube), any location
15730 - Midface flap (ie, zygomaticofacial flap) with preservation of vascular pedicle(s)
15731 - Forehead flap with preservation of vascular pedicle (eg, axial pattern flap, paramedian forehead flap)
15733 - Muscle, myocutaneous, or fasciocutaneous flap; head and neck with named vascular pedicle (i.e., buccinators, genioglossus, temporalis, masseter, sternocleidomastoid, levator scapulae)
15734 - Muscle, myocutaneous, or fasciocutaneous flap; trunk
15736 - Muscle, myocutaneous, or fasciocutaneous flap; upper extremity
15738 - Muscle, myocutaneous, or fasciocutaneous flap; lower extremity
15740 - Flap; island pedicle requiring identification and dissection of an anatomically named axial vessel
15750 - Flap; neurovascular pedicle
15922 - Excision, coccygeal pressure ulcer, with coccygectomy; with flap closure
15934 - Excision, sacral pressure ulcer, with skin flap closure
15936 - Excision, sacral pressure ulcer, in preparation for muscle or myocutaneous flap or skin graft closure
15944 - Excision, ischial pressure ulcer, with skin flap closure
15946 - Excision, ischial pressure ulcer, with ostectomy, in preparation for muscle or myocutaneous flap or skin graft closure
15952 - Excision, trochanteric pressure ulcer, with skin flap closure
15956 - Excision, trochanteric pressure ulcer, in preparation for muscle or myocutaneous flap or skin graft closure
49904 - Omental flap, extra-abdominal (eg, for reconstruction of sternal and chest wall defects)
49905 - Omental flap, intra-abdominal (List separately in addition to code for primary procedure)