MEDICAL POLICY – 7.01.113 Bioengineered Skin and Soft Tissue Substitutes BCBSA Ref. Policy: 7.01.113 Effective Date: April 1, 2020 Last Revised: June 25, 2020 Replaces: N/A

RELATED MEDICAL POLICIES: 7.01.149 Amniotic Membrane and Amniotic Fluid Injections

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POLICY CRITERIA | DOCUMENTATION REQUIREMENTS | CODING RELATED INFORMATION | EVIDENCE REVIEW | REFERENCES | HISTORY

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Introduction

Bioengineered skin and soft tissue substitutes are artificial alternatives to live skin grafts for wound care and tissue reconstruction. The products are made from various sources including human tissue (from the patient or others), nonhuman tissue (cows, pigs, horses), synthetic materials (man-made), or a combination of these materials. Some skin substitutes are labeled for specific uses such as for healing severe diabetic foot sores or during surgery for severe burns or breast reconstruction; other uses are being researched. This policy outlines when specific bioengineered skin and soft tissue substitutes might be medically necessary.

Note: The Introduction section is for your general knowledge and is not to be taken as policy coverage criteria. The

rest of the policy uses specific words and concepts familiar to medical professionals. It is intended for providers. A provider can be a person, such as a doctor, nurse, psychologist, or dentist. A provider also can be a place where medical care is given, like a hospital, clinic, or lab. This policy informs them about when a service may be covered.

Policy Coverage Criteria

http://ihub/sites/medicalpol/Active/7.01.149.pdf

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Products Medical Necessity Allogeneic Acellular Dermal Matrix Products, including but not limited to: • AlloDerm®* • AlloMend® • Cortiva® [AlloMax™] • DermACELL™ • DermaMatrix™* • FlexHD®* • FlexHD® Pliable™ • Graftjacket®*

Breast reconstructive surgery using allogeneic acellular dermal matrix products listed in the left column may be considered medically necessary when: • There is insufficient tissue expander or implant coverage by the

pectoralis major muscle and additional coverage is required OR • There is viable but compromised or thin postmastectomy skin

flaps that are at risk of dehiscence or necrosis OR • The inframammary fold and lateral mammary folds have been

undermined during mastectomy and reestablishment of these landmarks is needed

• AlloPatch®* • Apligraft®** • Dermagraf®** • Integra® Flowable

Wound Matrix • Integra® Omnigraft™

Dermal Regeneration Matrix (also known as Omnigraft™)

• Integra®Flowable Wound Matrix

Treatment of chronic, non-infected, full-thickness diabetic lower-extremity ulcers using the tissue-engineered skin substitute products listed in the left column may be considered medically necessary. Note: Criteria for using human amniotic membrane products are addressed in

a separate medical policy (see Related Policies).

• Apligraf®** • Oasis™ Wound Matrix***

Treatment of chronic, non-infected, partial or full-thickness lower-extremity skin ulcers due to venous insufficiency using the tissue-engineered skin substitute products listed in the left column may be considered medically necessary when: • A one-month period of conventional ulcer therapy has failed to

promote healing • OrCel™**** Treatment of dystrophic epidermolysis bullosa using the

tissue-engineered skin substitute product listed in the left column may be considered medically necessary when: • Standard wound therapy has failed for the treatment of mitten-

hand deformity AND • When provided in accordance with the humanitarian device

exemption (HDE) specifications of the U.S. Food and Drug Administration (FDA)****

https://ghr.nlm.nih.gov/condition/dystrophic-epidermolysis-bullosa

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Products Medical Necessity • Epicel ®**** • Integra ® Dermal

Regeneration Template**

Treatment of second- and third-degree burns using the tissue-engineered skin substitute products listed in the left column may be considered medically necessary when: • Epicel® only: It is used for the treatment of deep dermal or

full-thickness burns covering a total body surface area ≥30% when provided in accordance with the HDE specifications of the FDA****

• Integra® Dermal Regeneration Template™**: No additional criteria required

All other uses of the bioengineered skin and soft tissue substitutes listed above are considered investigational. *Banked human tissue; **FDA premarket approval; ***FDA 510(k) cleared; ****FDA-approved under an HDE

Note: Amniotic membrane and amniotic fluid products are reviewed in a Related Policy.

Investigational All other bioengineered skin and soft tissue substitute products not listed above are considered investigational, including, but not limited to: • ACell® UBM Hydrated

Wound Dressing • ACell® UBM Lyophilized

Wound Dressing • AlloSkin™ • AlloSkin™ RT • Aongen™ Collagen Matrix • Architect® ECM, PX, FX • ArthroFlex™ (Flex Graft) • Atlas Wound Matrix • Avagen Wound Dressing • AxoGuard® Nerve Protector

(AxoGen) • Biobrane®/Biobrane-L • CollaCare® • CollaCare® Dental • Collagen Wound Dressing

(Oasis Research) • CollaGUARD® • CollaMend™

• DermaSpan™ • DressSkin Durepair

Regeneration Matrix® • Endoform Dermal

Template™ • ENDURAGen™ • Excellagen • ExpressGraft™ • E-Z Derm™ • FlowerDerm • GammaGraft • Graftjacket® Xpress,

injectable • Helicoll™ • Hyalomatrix® • Hyalomatrix® PA • hMatrix® • Integra™ Bilayer Wound

Matrix • Keramatrix®

• Oasis® Ultra • Pelvicol®/PelviSoft® • Permacol™ • PriMatrix™ • PriMatrix™ Dermal Repair

Scaffold • PuraPly™ Wound Matrix

(previously FortaDerm™) • PuraPly™ AM (Antimicrobial

Wound Matrix) • Puros® Dermis • RegenePro™ • Repliform® • Repriza™ • StrataGraft® • Strattice™ (xenograft) • Suprathel® • SurgiMend® • Talymed® • TenoGlide™

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Investigational • CollaWound™ • Collexa® • Collieva® • Conexa™ • Coreleader Colla-Pad • CorMatrix® • Cymetra™ (Micronized

AlloDerm™ Tissue [MAT]) • Cytal™ (previously

MatriStem®) • Dermadapt™ Wound

Dressing • DermaPure™

• Kerecis™ • MariGen ™/Kerecis™

Omega3™ • MatriDerm® • Matrix HD™ • Mediskin® • MemoDerm™ • Microderm® biologic

wound matrix • NeoForm™ • NuCel • Oasis® Burn Matrix

• TenSIX™ Acellular Dermal Matrix

• TissueMend • TheraForm™

Standard/Sheet • TheraSkin® • TransCyte™ • TruSkin™ • Veritas® Collagen Matrix • XCM Biologic® Tissue

Matrix • XenMatrix™ AB

Documentation Requirements For wound care, detailed history and physical, with the record to include the following: • Associated medical comorbidities • Description of wound (eg, fullthickness [affecting all layers of the skin], deep dermal [deeper

than a superficial wound but not a full thickness wound]) • Standard wound therapy treatment provided, including duration and effectiveness or failure of

treatment

Coding

Code Description HCPCS Reviewed for coverage with supporting documentation Q4100 Skin substitute, not otherwise specified

Medically Necessary (Eligible for Coverage) Q4101 Apligraf, per square centimeter

Q4102 Oasis Wound Matrix, per square centimeter

Q4104 Integra Bilayer Matrix Wound Dressing (BMWD), per square centimeter

Q4105 Integra Dermal Regeneration Template (DRT), per square centimeter

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Code Description Q4106 Dermagraft, per square centimeter

Q4107 Graftjacket, per square centimeter

Q4108 Integra Matrix, per square centimeter

Q4116 AlloDerm, per square centimeter

Q4122 DermACELL, DermACELL AWM or DermACELL AWM Porous, per sq cm

Q4128 FlexHD, Allopatch HD or Matrix HD, per square centimeter

Investigational (Not Eligible for Coverage) A6460 Synthetic resorbable wound dressing, sterile, pad size 16 sq. in. or less, without

adhesive border, each dressing

A6461 Synthetic resorbable wound dressing, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., without adhesive border, each dressing

Q4103 Oasis Burn Matrix, per square centimeter

Q4110 PriMatrix, per square centimeter

Q4111 GammaGraft, per square centimeter

Q4112 Cymetra, injectable, 1 cc

Q4113 Graftjacket Xpress, injectable, 1 cc

Q4114 Integra Flowable Wound Matrix, injectable, 1 cc

Q4115 AlloSkin, per square centimeter

Q4117 Hyalomatrix, per square centimeter

Q4118 MatriStem micromatrix, 1 mg

Q4121 TheraSkin, per square centimeter

Q4123 AlloSkin RT, per square centimeter

Q4124 Oasis Ultra Tri-Layer Wound Matrix, per square centimeter

Q4125 Arthroflex, per square centimeter

Q4126 Memoderm, Dermaspan, Transgraft or Integuply, per square centimeter

Q4127 Talymed, per square centimeter

Q4130 Strattice TM, per square centimeter

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Code Description Q4134 hMatrix, per square centimeter

Q4135 Mediskin, per square centimeter

Q4136 EZ-derm, per square centimeter

Q4141 Alloskin AC, per square centimeter

Q4142 Xcm biologic tissue matrix, per square centimeter

Q4143 Repriza, per square centimeter

Q4146 TenSIX, per square centimeter

Q4147 Architect, Architect PX, or Architect FX, extracellular matrix, per square centimeter

Q4149 Excellagen, 0.1 cc

Q4152 DermaPure per square centimeter

Q4158 Kerecis Omega3, per sq cm

Q4161 Bio-ConneKt Wound Matrix, per square centimeter

Q4164 Helicoll, per square centimeter

Q4165 Keramatrix or Kerasorb, per square centimeter

Q4166 Cytal, per square centimeter

Q4167 Truskin, per square centimeter

Q4175 Miroderm, per square centimeter

Q4179 Flowerderm, per square centimeter

Q4182 Transcyte, per square centimeter

Q4193 Coll-e-derm, per square centimeter

Q4195 Puraply, per square centimeter

Q4196 Puraply am, per square centimeter

Q4197 Puraply xt, per square centimeter

Q4200 Skin te, per square centimeter

Q4203 Derma-gide, per square centimeter

Q4220 BellaCell HD or Surederm, per sq cm (code effective 10/1/19)

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Code Description Q4222 ProgenaMatrix, per sq cm (code effective 10/1/19)

Q4226 MyOwn Skin, includes harvesting and preparation procedures, per sq cm (code effective 10/1/19)

Q4238 Derm-Maxx, per sq cm (code effective 7/1/20)

Modifiers JC Skin substitute used as a graft

JD Skin substitute not used as a graft

Related Information

Clinical input has indicated that the various acellular dermal matrix products used in breast reconstruction have similar efficacy. The products listed are those that have been identified for use in breast reconstruction. Additional acellular dermal matrix products may become available for this indication.

Benefit Application

Many states have mandates related to breast reconstruction that may impact the application of this policy.

Evidence Review

Description

Bioengineered skin and soft tissue substitutes may be derived from human tissue (autologous or allogeneic), nonhuman tissue (xenographic), synthetic materials, or a composite of these materials. Bioengineered skin and soft tissue substitutes are being evaluated for a variety of conditions, including breast reconstruction and healing lower-extremity ulcers and severe burns. Acellular dermal matrix (ADM) products are also being evaluated for soft tissue repair.

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Background

Skin and Soft Tissue Substitutes

Bioengineered skin and soft tissue substitutes may be either acellular or cellular. Acellular products (eg, dermis with cellular material removed) contain a matrix or scaffold composed of materials such as collagen, hyaluronic acid, and fibronectin. Acellular dermal matrix (ADM) products can differ in a number of ways, including the species source (human, bovine, porcine), tissue source (eg, dermis, pericardium, intestinal mucosa), additives (eg, antibiotics, surfactants), hydration (wet, freeze dried), and required preparation (multiple rinses, rehydration).

Cellular products contain living cells such as fibroblasts and keratinocytes within a matrix. The cells contained within the matrix may be autologous, allogeneic, or derived from other species (eg, bovine, porcine). Skin substitutes may also be composed of dermal cells, epidermal cells, or a combination of dermal and epidermal cells, and may provide growth factors to stimulate healing. Bioengineered skin substitutes can be used as either temporary or permanent wound coverings.

Applications

There are a large number of potential applications for artificial skin and soft tissue products. One large category is nonhealing wounds, which potentially encompasses diabetic neuropathic ulcers, vascular insufficiency ulcers, and pressure ulcers. A substantial minority of such wounds do not heal adequately with standard wound care, leading to prolonged morbidity and increased risk of mortality. For example, nonhealing lower-extremity wounds represent an ongoing risk for infection, sepsis, limb amputation, and death. Bioengineered skin and soft tissue substitutes have the potential to improve rates of healing and reduce secondary complications.

Other situations in which bioengineered skin products might substitute for living skin grafts include certain postsurgical states (eg, breast reconstruction) in which skin coverage is inadequate for the procedure performed, or for surgical wounds in patients with compromised ability to heal. Second and third-degree burns are another indication in which artificial skin products may substitute for autografts or allografts. Certain primary dermatologic conditions that involve large areas of skin breakdown (eg, bullous diseases) may also be conditions in which artificial skin products can be considered as substitutes for skin grafts. ADM products are

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also being evaluated in the repair of other soft tissues including rotator cuff repair, following oral and facial surgery, hernias, and other conditions.

Summary of Evidence

Breast Reconstruction

For individuals who are undergoing breast reconstruction who receive allogeneic ADM products, the evidence includes randomized controlled trials (RCTs) and systematic reviews. Relevant outcomes are symptoms, morbid events, functional outcomes, quality of life, and treatment-related morbidity. A systematic review found no difference in overall complication rates with ADM allograft compared with standard procedures for breast reconstruction. Reconstructions with ADM have been reported to have higher seroma, infection, and necrosis rates than reconstructions without ADM. However, capsular contracture and malposition of implants may be reduced. Thus, in cases where there is limited tissue coverage, the available evidence may inform patient decision making about reconstruction options. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

Tendon Repair

For individuals who are undergoing tendon repair who receive Graftjacket, the evidence incudes an RCT. Relevant outcomes are symptoms, morbid events, functional outcomes, quality of life, and treatment-related morbidity. The RCT identified improved outcomes with Graftjacket ADM allograft for rotator cuff repair. Although these results were positive, additional study with a larger number of patients is needed to evaluate consistency of the effect. The evidence is insufficient to determine the effects of the technology on health outcomes.

Surgical Repair of Hernias or Parastomal Reinforcement

For individuals who are undergoing surgical repair of hernias or parastomal reinforcement who receive acellular collagen-based scaffolds, the evidence incudes RCTs. Relevant outcomes are symptoms, morbid events, functional outcomes, quality of life, and treatment-related morbidity. Several comparative studies including RCTs have shown no difference in outcomes between tissue-engineered skin substitutes and either standard synthetic mesh or no reinforcement. The

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evidence is sufficient to determine that the technology is unlikely to improve the net health outcome.

Diabetic Lower-Extremity Ulcers

For individuals who have diabetic lower-extremity ulcers who receive AlloPatch, Apligraf, Dermagraft, or Integra, the evidence includes RCTs. Relevant outcomes are symptoms, change in disease status, morbid events, and quality of life. RCTs have demonstrated the efficacy of AlloPatch (reticular ADM), Apligraf and Dermagraft (living cell therapy), and Integra (biosynthetic) over the standard of care. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

For individuals who have diabetic lower-extremity ulcers who receive ADM products other than AlloPatch, Apligraf, Dermagraft, or Integra, the evidence includes RCTs. Relevant outcomes are symptoms, change in disease status, morbid events, and quality of life. Results from a multicenter RCT showed some benefit of DermACELL that was primarily for the subgroup of patients who only required a single application of the ADM. Studies are needed to further define the population who might benefit from this treatment. Additional study with a larger number of subjects is needed to evaluate the effect of Graftjacket, TheraSkin, DermACELL, Cytal, PriMatrix, and Oasis Wound Matrix, compared with current SOC or other advanced wound therapies. The evidence is insufficient to determine the effects of the technology on health outcomes.

Lower-Extremity Ulcers Due to Venous Insufficiency

For individuals who have lower-extremity ulcers due to venous insufficiency who receive Apligraf or Oasis Wound Matrix, the evidence includes RCTs. Relevant outcomes are symptoms, change in disease status, morbid events, and quality of life. RCTs have demonstrated the efficacy of Apligraf living cell therapy and xenogenic Oasis Wound Matrix over the standard of care. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

For individuals who have lower-extremity ulcers due to venous insufficiency who receive bioengineered skin substitutes other than Apligraf or Oasis Wound Matrix, the evidence includes RCTs. Relevant outcomes are disease-specific survival, symptoms, change in disease status, morbid events, and quality of life. In a moderately large RCT, Dermagraft was not shown to be more effective than controls for the primary or secondary end points in the entire population and was only slightly more effective than controls (an 8%-15% increase in healing) in subgroups

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of patients with ulcer durations of 12 months or less or size of 10 cm or less. Additional study with a larger number of subjects is needed to evaluate the effect of the xenogenic PriMatrix skin substitute versus the current standard of care. The evidence is insufficient to determine the effects of the technology on health outcomes.

Dystrophic Epidermolysis Bullosa

For individuals who have dystrophic epidermolysis bullosa who receive OrCel, the evidence includes case series. Relevant outcomes are symptoms, change in disease status, morbid events, and quality of life. OrCel was approved under a humanitarian drug exemption for use in patients with dystrophic epidermolysis bullosa undergoing hand reconstruction surgery, to close and heal wounds created by the surgery, including those at donor sites. Outcomes have been reported in small series (eg, 5 patients). The evidence is insufficient to determine the effects of the technology on health outcomes.

Deep Dermal Burns

For individuals who have deep dermal burns who receive bioengineered skin substitutes (ie, Epicel, Integra Dermal Regeneration Template), the evidence includes RCTs. Relevant outcomes are symptoms, change in disease status, morbid events, functional outcomes, quality of life, and treatment-related morbidity. Overall, few skin substitutes have been approved, and the evidence is limited for each product. Epicel (living cell therapy) has received FDA approval under a humanitarian device exemption for the treatment of deep dermal or full-thickness burns comprising a total body surface area of 30% or more. Comparative studies have demonstrated improved outcomes for biosynthetic skin substitute Integra Dermal Regeneration Template for the treatment of burns. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome.

Ongoing and Unpublished Clinical Trials

Some currently ongoing and unpublished trials that might influence this review are listed in Table 1.

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Table 1. Summary of Key Trials

NCT No. Trial Name Planned Enrollment

Completion Date

Ongoing NCT03285698 A Randomized, Prospective Trial Comparing the Clinical

Outcomes for DermACELL® Compared With Integra® Bilayer Wound Matrix

100 Oct 2020

NCT02587403a A Randomized, Prospective Study Comparing Fortiva™ Porcine Dermis vs. Strattice™ Reconstructive Tissue Matrix in Patients Undergoing Complex Open Primary Ventral Hernia Repair

120 Oct 2020

NCT02322554 The Registry of Cellular and Tissue Based Therapies for Chronic Wounds and Ulcers

50,000 Jan 2020

Unpublished NCT01987700a Multi-Center Study To Examine The Use Of Flex HD® And

Strattice In The Repair Of Large Abdominal Wall Hernias 120 Aug 2018

(completed)

NCT: national clinical trial. a Denotes industry-sponsored or cosponsored trial.

Clinical Input Received from Physician Specialty Societies and Academic Medical Centers

While the various physician specialty societies and academic medical centers may collaborate with and make recommendations during this process, through the provision of appropriate reviewers, input received does not represent an endorsement or position statement by the physician specialty societies or academic medical centers, unless otherwise noted.

2016 Input

In response to requests, input was received from two physician specialty societies and three academic medical centers while this policy was under review in 2016. Input was requested on the equivalency of products within the categories of amniotic membrane, living cell therapies, and biosynthetic skin substitutes for the treatment of diabetic foot ulcers and non-ocular burns (biosynthetic only). Input on the equivalency of products within these categories was mixed.

https://clinicaltrials.gov/ct2/show/NCT03285698https://clinicaltrials.gov/ct2/show/NCT02587403?term=NCT02587403&rank=1https://clinicaltrials.gov/ct2/show/NCT02322554?term=NCT02322554&rank=1https://clinicaltrials.gov/ct2/show/NCT01987700?term=NCT01987700&rank=1

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2014 Input

In response to requests, input was received from 3 physician specialty societies and 4 academic medical centers while this policy was under review in 2014. In addition to questions on medical necessity for different indications, input was specifically requested on the equivalency of products within the different categories (eg, acellular dermal matrix [ADM], living cell therapy, xenogeneic collagen scaffold, amniotic membrane). Five reviewers addressed the use of ADM products for breast reconstruction, and most considered the various ADM products (AlloDerm, AlloMax, DermaMatrix, FlexHD, Graftjacket) to have similar outcomes when used for breast reconstructive surgery, although differences in firmness and stretch of the products were noted. Six reviewers addressed questions on bioengineered skin and soft tissue substitutes for diabetic and venous lower-extremity ulcers. Responses were mixed, although most reviewers considered living cell therapies to be equivalent for these indications. Most reviewers did not consider xenogeneic ADM products (eg, PriMatrix) or amniotic membrane (eg, EpiFix) to be medically necessary for any indication.

2012 Input

In response to requests, input was received from three physician specialty societies and two academic medical centers while this policy was under review in 2012. Most reviewers supported the indications and products described in this policy. Input was requested on the use of an interpositional spacer after parotidectomy. Support for this indication was mixed. Some reviewers suggested use of other products and/or additional indications; however, the input on these products/indications was not uniform. Reviewers provided references for the additional indications; these were subsequently reviewed.

2009 Input

In response to requests, input was received from one physician specialty society (two physicians) and one academic medical center while this policy was under review in 2009. All reviewers indicated that the use of AlloDerm in breast reconstruction surgery should be available for use during breast reconstructive surgery.

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Practice Guidelines and Position Statements

National Institute for Health and Care Excellence

In 2019, the National Institute for Health and Care Excellence updated its guidance on the prevention and management of diabetic foot problems.67 The Institute recommended that clinicians “consider dermal or skin substitutes as an adjunct to standard care when treating diabetic foot ulcers, only when healing has not progressed and on the advice of the multidisciplinary foot care service.”

It was emphasized that none of these measures had been shown to improve the resolution of infection and that they were expensive, not universally available, might require consultation with experts, and reports supporting their utility were mostly flawed.

Medicare National Coverage

The Centers for Medicare & Medicaid Services (CMS) issued the following national coverage determination: porcine (pig) skin dressings are covered, if reasonable and necessary for the individual patient as an occlusive dressing for burns, donor sites of a homograft, and decubiti and other ulcers.68

In 2019, CMS reported that it is finalizing the proposal to continue the policy established in CY 2018 to assign skin substitutes to the low cost or high-cost group.69 In addition, CMS presented several payment ideas to change how skin substitute products are paid and solicited comments on these ideas to be used for future rulemaking.

Regulatory Status

A large number of artificial skin products are commercially available or in development. The following summary of commercially available skin substitutes describes those products that have substantial relevant evidence on efficacy.

Acellular Dermal Matrix (ADM) Products

Allograft ADM products derived from donated human skin tissue are supplied by tissue banks compliant with standards of the American Association of Tissue Banks and U.S. Food and Drug

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Administration (FDA) guidelines. The processing removes the cellular components (ie, epidermis, all viable dermal cells) that can lead to rejection and infection. ADM products from human skin tissue are regarded as minimally processed and not significantly changed in structure from the natural material; FDA classifies ADM products as banked human tissue and therefore not requiring FDA approval for homologous use.

In 2017, FDA published clarification of what is considered minimal manipulation and homologous use for human cells, tissues, and cellular and tissue-based products (HCT/Ps).3

HCT/Ps are defined as human cells or tissues that are intended for implantation, transplantation, infusion, or transfer into a human recipient. If an HCT/P does not meet the criteria below and does not qualify for any of the stated exceptions, the HCT/P will be regulated as a drug, device, and/or biological product and applicable regulations and premarket review will be required.

An HCT/P is regulated solely under section 361 of the PHS Act and 21 CFR Part 1271 if it meets all of the following criteria:

1. The HCT/P is minimally manipulated;

2. The HCT/P is intended for homologous use only, as reflected by the labeling, advertising, or other indications of the manufacturer’s objective intent;

3. The manufacture of the HCT/P does not involve the combination of the cells or tissues with another article, except for water, crystalloids, or a sterilizing, preserving, or storage agent, provided that the addition of water, crystalloids, or the sterilizing, preserving, or storage agent does not raise new clinical safety concerns with respect to the HCT/P; and

4. Either:

i. The HCT/P does not have a systemic effect and is not dependent upon the metabolic activity of living cells for its primary function; or

ii. The HCT/P has a systemic effect or is dependent upon the metabolic activity of living cells for its primary function, and: a) Is for autologous use; b) Is for allogeneic use in a first-degree or second-degree blood relative; or c) Is for reproductive use.

Although frequently used by surgeons for breast reconstruction, FDA does not consider this homologous use and has not cleared or approved any surgical mesh device (synthetic, animal collagen-derived, or human collagen-derived) for use in breast surgery. The indication of surgical mesh for general use in “Plastic and reconstructive surgery” was cleared by the FDA before surgical mesh was described for breast reconstruction in 2005. FDA states that the specific use of surgical mesh in breast procedures represents a new intended use and that a

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substantial equivalence evaluation via 510(k) review is not appropriate and a pre-market approval evaluation is required.4

• AlloDerm® (LifeCell Corp.) is an ADM (allograft) tissue-replacement product created from native human skin and processed so that the basement membrane and cellular matrix remain intact. Originally, AlloDerm® required refrigeration and rehydration before use. It is currently available in a ready-to-use product stored at room temperature. An injectable micronized form of AlloDerm® (Cymetra) is available.

• Cortiva® (previously marketed as AlloMax™ Surgical Graft, and before that as NeoForm™) is an acellular non-cross-linked human dermis allograft.

• AlloPatch® (Musculoskeletal Transplant Foundation) is an acellular human dermis allograft derived from the reticular layer of the dermis and marketed for wound care. This product is also marketed as FlexHD® for postmastectomy breast reconstruction.

• FlexHD® and the newer formulation FlexHD® Pliable™ (Musculoskeletal Transplant Foundation) are acellular hydrated reticular dermis allograft derived from donated human skin.

• DermACELL™ (LifeNet Health) is an allogeneic ADM processed with proprietary technologies MATRACELL® and PRESERVON®.

• DermaMatrix™ (Synthes) is a freeze-dried ADM derived from donated human skin tissue. DermaMatrix Acellular Dermis is processed by the Musculoskeletal Transplant Foundation.

• DermaPure™ (Tissue Regenix Wound Care) is a singlelayer decellularized human dermal allograft for the treatment of acute and chronic wounds.

• Graftjacket® Regenerative Tissue Matrix (also called Graftjacket Skin Substitute; KCI) is an acellular regenerative tissue matrix that has been processed from human skin supplied from U.S. tissue banks. The allograft is minimally processed to remove the epidermal and dermal cells, while preserving dermal structure. Graftjacket Xpress® is an injectable product.

FDA product codes: FTM, OXF.

Xenogenic Products

• Cytal™ (previously called MatriStem®) Wound Matrix, Multilayer Wound Matrix, Pelvic Floor Matrix, MicroMatrix, and Burn Matrix (all manufactured by ACell) are composed of porcine-derived urinary bladder matrix.

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• Helicoll (Encol) is an acellular collagen matrix derived from bovine dermis. In 2004, it was cleared for marketing by FDA through the 510(k) process for topical wound management that includes partial and full-thickness wounds, pressure ulcers, venous ulcers, chronic vascular ulcers, diabetic ulcers, trauma wounds (eg, abrasions, lacerations, second-degree bums, skin tears), and surgical wounds including donor sites/grafts.

• Keramatrix® (Keraplast Research) is an open-cell foam comprised of freeze-dried keratin that is derived from acellular animal protein. In 2009, it was cleared for marketing by FDA through the 510(k) process under the name of Keratec. The wound dressings are indicated in the management of the following types of dry, light, and moderately exudating partial and full-thickness wounds: pressure (stage I-IV) and venous stasis ulcers, ulcers caused by mixed vascular etiologies, diabetic ulcers, donor sites, and grafts.

• Kerecis™ Omega3 Wound (Kerecis) is an ADM derived from fish skin. It has a high content of omega 3 fatty acids and is intended for use in burn wounds, chronic wounds, and other applications.

• Permacol™ (Covidien) is xenogeneic and composed of cross-linked porcine dermal collagen. Cross-linking improves the tensile strength and long-term durability but decreases pliability.

• PriMatrix™ (TEI Biosciences, a subsidiary of Integra Life Sciences) is a xenogeneic ADM processed from fetal bovine dermis. It was cleared for marketing by FDA through the 510(k) process for partial and full-thickness wounds; diabetic, pressure, and venous stasis ulcers; surgical wounds; and tunneling, draining, and traumatic wounds. FDA product code: KGN.

• SurgiMend® PRS (TEI Biosciences, a subsidiary of Integra Life Sciences) is a xenogeneic ADM processed from fetal and neonatal bovine dermis.

• Strattice™ Reconstructive Tissue Matrix (LifeCell Corp) is a xenogenic non-cross-linked porcine-derived ADM. There are pliable and firm versions, which are stored at room temperature and come fully hydrated.

• Oasis™ Wound Matrix (Cook Biotech) is a collagen scaffold (extracellular matrix) derived from porcine small intestinal mucosa. In 2000, it was cleared for marketing by FDA through the 510(k) process for the management of partial and full-thickness wounds, including pressure ulcers, venous ulcers, diabetic ulcers, chronic vascular ulcers, tunneled undermined wounds, surgical wounds, trauma wounds, and draining wounds. FDA Product code: KGN.

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Living Cell Therapy

• Apligraf® (Organogenesis) is a bilayered living cell therapy composed of an epidermal layer of living human keratinocytes and a dermal layer of living human fibroblasts. Apligraf® is supplied as needed, in 1 size, with a shelf-life of 10 days. In 1998, it was approved by FDA for use in conjunction with compression therapy for the treatment of noninfected, partial- and full-thickness skin ulcers due to venous insufficiency and in 2001 for full-thickness neuropathic diabetic lower-extremity ulcers nonresponsive to standard wound therapy. FDA product code: FTM.

• Dermagraft® (Organogenesis) is composed of cryopreserved human-derived fibroblasts and collagen derived from newborn human foreskin and cultured on a bioabsorbable polyglactin mesh scaffold. Dermagraft has been approved by FDA for repair of diabetic foot ulcers. FDA product code: PFC.

• Epicel® (Genzyme Biosurgery) is an epithelial autograft composed of a patient’s own keratinocytes cultured ex vivo and is FDA-approved under a humanitarian device exemption (HDE) for the treatment of deep dermal or full-thickness burns comprising a total body surface area of 30% or more. It may be used in conjunction with split-thickness autografts or alone in patients for whom split-thickness autografts may not be an option due to the severity and extent of their burns. FDA product code: OCE.

• OrCel™ (Forticell Bioscience; formerly Composite Cultured Skin) is an absorbable allogeneic bilayered cellular matrix, made of bovine collagen, in which human dermal cells have been cultured. It was approved by FDA premarket approval for healing donor site wounds in burn victims and under a humanitarian device exemption (HDE) for use in patients with recessive dystrophic epidermolysis bullosa undergoing hand reconstruction surgery to close and heal wounds created by the surgery, including those at donor sites. FDA product code: ODS.

• TheraSkin® (Soluble Systems) is a cryopreserved split-thickness human skin allograft composed of living fibroblasts and keratinocytes and an extracellular matrix in epidermal and dermal layers. TheraSkin® is derived from human skin allograft supplied by tissue banks compliant with the AATB and FDA guidelines. It is considered a minimally processed human cell, tissue, and cellular- and tissue-based product by FDA.

Biosynthetic Products

• Biobrane®/Biobrane-L (Smith and Nephew) is a biosynthetic wound dressing constructed of a silicon film with a nylon fabric partially imbedded into the film. The fabric creates a

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complex 3-dimensional structure of tri-filament thread, which chemically binds collagen. Blood/sera clot in the nylon matrix, adhering the dressing to the wound until epithelialization occurs. FDA product code: FRO.

• Integra® Dermal Regeneration Template (also marketed as Omnigraft Dermal Regeneration Matrix; Integra LifeSciences) is a bovine, collagen/glycosaminoglycan dermal replacement covered by a silicone temporary epidermal substitute. It was approved by FDA for use in the post-excisional treatment of life-threatening full-thickness or deep partial-thickness thermal injury where sufficient autograft is not available at the time of excision or not desirable because of the physiologic condition of the patient and for certain diabetic foot ulcers.

• Integra® Matrix Wound Dressing and Integra® Meshed Bilayer Wound Matrix are substantially equivalent skin substitutes and were cleared for marketing by FDA through the 510(k) process for other indications. Integra® Bilayer Wound Matrix (Integra LifeSciences) is designed to be used in conjunction with negative pressure wound therapy. The meshed bilayer provides a flexible wound covering and allows drainage of wound exudate. FDA product code: MDD.

• TransCyte™ (Advanced Tissue Sciences) consists of human dermal fibroblasts grown on nylon mesh, combined with a synthetic epidermal layer and was approved by the FDA in 1997. TransCyte is intended as a temporary covering over burns until autografting is possible. It can also be used as a temporary covering for some burn wounds that heal without autografting.

Synthetic Products

• Suprathel® (PolyMedics Innovations) is a synthetic copolymer membrane fabricated from a tri-polymer of polylactide, trimethylene carbonate, and s-caprolactone. It is used to provide temporary coverage of superficial dermal burns and wounds. Suprathel® is covered with gauze and a dressing that is left in place until the wound has healed.

References

1. Whitelaw GP, DeMuth KA, Demos HA et al. The use of the Cryo/Cuff versus ice and elastic wrap in the postoperative care of knee arthroscopy patients. Am J Knee Surg. 1995 Winter;8(1). PMID 7866800

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2. Healy WL, Seidman J, Pfeifer BA et al. Cold compressive dressing after total knee arthroplasty. Clin. Orthop. Relat. Res. 1994 Feb;143-6(299). PMID 7907012

3. U.S. Food and Drug Administration. Regulatory Considerations for Human Cells, Tissues, and Cellular and Tissue-Based Products: Minimal Manipulation and Homologous Use. December 2017. https://www.fda.gov/media/124138/download . Accessed March 2020.

4. U.S. Food and Drug Administration. Executive Summary Breast Implant Special Topics. March 2019. https://www.fda.gov/media/122956/download . Accessed March 2020

5. Davila AA, Seth AK, Wang E, et al. Human acellular dermis versus submuscular tissue expander breast reconstruction: a multivariate analysis of short-term complications. Arch Plast Surg. Jan 2013;40(1):19-27. PMID 23362476

6. Lee KT, Mun GH. Updated evidence of acellular dermal matrix use for implant-based breast reconstruction: a meta-analysis. Ann Surg Oncol. Feb 2016;23(2):600-610. PMID 26438439

7. McCarthy CM, Lee CN, Halvorson EG, et al. The use of acellular dermal matrices in two-stage expander/implant reconstruction: a multicenter, blinded, randomized controlled trial. Plast Reconstr Surg. Nov 2012;130(5 Suppl 2):57S-66S. PMID 23096987

8. Hinchcliff KM, Orbay H, Busse BK, et al. Comparison of two cadaveric acellular dermal matrices for immediate breast reconstruction: A prospective randomized trial. J Plast Reconstr Aesthet Surg. May 2017;70(5):568-576. PMID 28341592

9. Mendenhall SD, Anderson LA, Ying J, et al. The BREASTrial Stage II: ADM breast reconstruction outcomes from definitive reconstruction to 3 months postoperative. Plast Reconstr Surg Glob Open. Jan 2017;5(1):e1209. PMID 28203509

10. Liu DZ, Mathes DW, Neligan PC, et al. Comparison of outcomes using AlloDerm versus FlexHD for implant-based breast reconstruction. Ann Plast Surg. May 2014;72(5):503-507. PMID 23636114

11. Chang EI, Liu J. Prospective unbiased experience with three acellular dermal matrices in breast reconstruction. J Surg Oncol. Sep 2017;116(3):365-370. PMID 28444764

12. Pittman TA, Fan KL, Knapp A, et al. Comparison of Different Acellular Dermal Matrices in Breast Reconstruction: The 50/50 Study. Plast Reconstr Surg. Mar 2017;139(3):521-528. PMID 28234811

13. Dikmans RE, Negenborn VL, Bouman MB, et al. Two-stage implant-based breast reconstruction compared with immediate one-stage implant-based breast reconstruction augmented with an acellular dermal matrix: an open-label, phase 4, multicentre, randomised, controlled trial. Lancet Oncol. Feb 2017;18(2):251-258. PMID 28012977

14. Barber FA, Burns JP, Deutsch A, et al. A prospective, randomized evaluation of acellular human dermal matrix augmentation for arthroscopic rotator cuff repair. Arthroscopy. Jan 2012;28(1):8-15. PMID 21978432

15. Bellows CF, Smith A, Malsbury J, et al. Repair of incisional hernias with biological prosthesis: a systematic review of current evidence. Am J Surg. Jan 2013;205(1):85-101. PMID 22867726

16. Espinosa-de-los-Monteros A, de la Torre JI, Marrero I, et al. Utilization of human cadaveric acellular dermis for abdominal hernia reconstruction. Ann Plast Surg. Mar 2007;58(3):264-267. PMID 17471129

17. Gupta A, Zahriya K, Mullens PL, et al. Ventral herniorrhaphy: experience with two different biosynthetic mesh materials, Surgisis and Alloderm. Hernia. Oct 2006;10(5):419-425. PMID 16924395

18. Bochicchio GV, De Castro GP, Bochicchio KM, et al. Comparison study of acellular dermal matrices in complicated hernia surgery. J Am Coll Surg. Oct 2013;217(4):606-613. PMID 23973102

19. Roth JS, Zachem A, Plymale MA, et al. Complex ventral hernia repair with acellular dermal matrices: clinical and quality of life outcomes. Am Surg. Feb 1 2017;83(2):141-147. PMID 28228200

20. Bellows CF, Shadduck P, Helton WS, et al. Early report of a randomized comparative clinical trial of Strattice reconstructive tissue matrix to lightweight synthetic mesh in the repair of inguinal hernias. Hernia. Apr 2014;18(2):221-230. PMID 23543334

21. Fleshman JW, Beck DE, Hyman N, et al. A prospective, multicenter, randomized, controlled study of non-cross- linked porcine acellular dermal matrix fascial sublay for parastomal reinforcement in patients undergoing surgery for permanent abdominal wall ostomies. Dis Colon Rectum. May 2014;57(5):623-631. PMID 24819103

https://www.fda.gov/media/124138/downloadhttps://www.fda.gov/media/122956/download

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22. Santema TB, Poyck PP, Ubbink DT. Skin grafting and tissue replacement for treating foot ulcers in people with diabetes. Cochrane Database Syst Rev. Feb 11 2016;2:CD011255. PMID 26866804

23. Martinson M, Martinson N. A comparative analysis of skin substitutes used in the management of diabetic foot ulcers. J Wound Care. Oct 2016;25(Sup10):S8-S17. PMID 27681811

24. Guo X, Mu D, Gao F. Efficacy and safety of acellular dermal matrix in diabetic foot ulcer treatment: A systematic review and meta-analysis. Int J Surg. Apr 2017;40:1-7. PMID 28232031

25. Veves A, Falanga V, Armstrong DG, et al. Graftskin, a human skin equivalent, is effective in the management of noninfected neuropathic diabetic foot ulcers: a prospective randomized multicenter clinical trial. Diabetes Care. Feb 2001;24(2):290-295. PMID 11213881

26. Blue Cross and Blue Shield Technology Evaluation Center (TEC). Graftskin for the treatment of skin ulcers. TEC Assessments. 2001;Volume 16:Tab 12.

27. Steinberg JS, Edmonds M, Hurley DP, Jr., et al. Confirmatory data from EU study supports Apligraf for the treatment of neuropathic diabetic foot ulcers. J Am Podiatr Med Assoc. Jan-Feb 2010;100(1):73-77. PMID 20093548

28. Kirsner RS, Warriner R, Michela M, et al. Advanced biological therapies for diabetic foot ulcers. Arch Dermatol. Aug 2010;146(8):857-862. PMID 20713816

29. Marston WA, Hanft J, Norwood P, et al. The efficacy and safety of Dermagraft in improving the healing of chronic diabetic foot ulcers: results of a prospective randomized trial. Diabetes Care. Jun 2003;26(6):1701-1705. PMID 12766097

30. Frykberg RG, Marston WA, Cardinal M. The incidence of lower-extremity amputation and bone resection in diabetic foot ulcer patients treated with a human fibroblast-derived dermal substitute. Adv Skin Wound Care. Jan 2015;28(1):17-20. PMID 25407083

31. Zelen CM, Orgill DP, Serena T, et al. A prospective, randomised, controlled, multicentre clinical trial examining healing rates, safety and cost to closure of an acellular reticular allogenic human dermis versus standard of care in the treatment of chronic diabetic foot ulcers. Int Wound J. Apr 2017;14(2):307-315. PMID 27073000

32. Zelen CM, Orgill DP, Serena TE, et al. An aseptically processed, acellular, reticular, allogenic human dermis improves healing in diabetic foot ulcers: A prospective, randomised, controlled, multicentre follow-up trial. International wound journal. Oct 2018;15(5):731-739. PMID 29682897

33. Driver VR, Lavery LA, Reyzelman AM, et al. A clinical trial of Integra Template for diabetic foot ulcer treatment. Wound Repair Regen. Nov 12 2015;23(6):891-900. PMID 26297933

34. Campitiello F, Mancone M, Della Corte A, et al. To evaluate the efficacy of an acellular Flowable matrix in comparison with a wet dressing for the treatment of patients with diabetic foot ulcers: a randomized clinical trial. Updates Surg. Dec 2017;69(4):523-529. PMID 28497218

35. Brigido SA, Boc SF, Lopez RC. Effective management of major lower extremity wounds using an acellular regenerative tissue matrix: a pilot study. Orthopedics. Jan 2004;27(1 Suppl):s145-149. PMID 14763548

36. Reyzelman A, Crews RT, Moore JC, et al. Clinical effectiveness of an acellular dermal regenerative tissue matrix compared to standard wound management in healing diabetic foot ulcers: a prospective, randomised, multicentre study. Int Wound J. Jun 2009;6(3):196-208. PMID 19368581

37. Reyzelman AM, Bazarov I. Human acellular dermal wound matrix for treatment of DFU: literature review and analysis. J Wound Care. Mar 2015;24(3):128; 129-134. PMID 25764957

38. Brigido SA. The use of an acellular dermal regenerative tissue matrix in the treatment of lower extremity wounds: a prospective 16-week pilot study. Int Wound J. Sep 2006;3(3):181-187. PMID 16984575

39. Walters J, Cazzell S, Pham H, et al. Healing rates in a multicenter assessment of a sterile, room temperature, acellular dermal matrix versus conventional care wound management and an active comparator in the treatment of full-thickness diabetic foot ulcers. Eplasty. Mar 2016;16:e10. PMID 26933467

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40. Cazzell S, Vayser D, Pham H, et al. A randomized clinical trial of a human acellular dermal matrix demonstrated superior healing rates for chronic diabetic foot ulcers over conventional care and an active acellular dermal matrix comparator. Wound Repair Regen. May 2017;25(3):483-497. PMID 28544150

41. Sanders L, Landsman AS, Landsman A, et al. A prospective, multicenter, randomized, controlled clinical trial comparing a bioengineered skin substitute to a human skin allograft. Ostomy Wound Manage. Sep 2014;60(9):26-38. PMID 25211605

42. DiDomenico L, Landsman AR, Emch KJ, et al. A prospective comparison of diabetic foot ulcers treated with either a cryopreserved skin allograft or a bioengineered skin substitute. Wounds. Jul 2011;23(7):184-189. PMID 25879172

43. Frykberg RG, Cazzell SM, Arroyo-Rivera J, et al. Evaluation of tissue engineering products for the management of neuropathic diabetic foot ulcers: an interim analysis. J Wound Care. Jul 2016;25 Suppl 7:S18-25. PMID 27410467

44. Kavros SJ, Dutra T, Gonzalez-Cruz R, et al. The use of PriMatrix, a fetal bovine acellular dermal matrix, in healing chronic diabetic foot ulcers: a prospective multicenter study. Adv Skin Wound Care. Aug 2014;27(8):356- 362. PMID 25033310

45. Karr JC. Retrospective comparison of diabetic foot ulcer and venous stasis ulcer healing outcome between a dermal repair scaffold (PriMatrix) and a bilayered living cell therapy (Apligraf). Adv Skin Wound Care. Mar 2011;24(3):119-125. PMID 21326023

46. Niezgoda JA, Van Gils CC, Frykberg RG, et al. Randomized clinical trial comparing OASIS Wound Matrix to Regranex Gel for diabetic ulcers. Adv Skin Wound Care. Jun 2005;18(5 Pt 1):258-266. PMID 15942317

47. Uccioli L, Giurato L, Ruotolo V, et al. Two-step autologous grafting using HYAFF scaffolds in treating difficult diabetic foot ulcers: results of a multicenter, randomized controlled clinical trial with long-term follow-up. The international journal of lower extremity wounds. Jun 2011;10(2):80-85. PMID 21693443

48. O'Meara S, Cullum N, Nelson EA et al. Compression for venous leg ulcers. Cochrane Database Syst Rev, 2012 Nov 16;11:CD000265. PMID 23152202

49. Falanga V, Margolis D, Alvarez O, et al. Rapid healing of venous ulcers and lack of clinical rejection with an allogeneic cultured human skin equivalent. Human Skin Equivalent Investigators Group. Arch Dermatol. Mar 1998;134(3):293-300. PMID 9521027

50. Mostow EN, Haraway GD, Dalsing M, et al. Effectiveness of an extracellular matrix graft (OASIS Wound Matrix) in the treatment of chronic leg ulcers: a randomized clinical trial. J Vasc Surg. May 2005;41(5):837-843. PMID 15886669

51. Romanelli M, Dini V, Bertone M, et al. OASIS wound matrix versus Hyaloskin in the treatment of difficult-to-heal wounds of mixed arterial/venous aetiology. Int Wound J. Mar 2007;4(1):3-7. PMID 17425543

52. Romanelli M, Dini V, Bertone MS. Randomized comparison of OASIS wound matrix versus moist wound dressing in the treatment of difficult-to-heal wounds of mixed arterial/venous etiology. Adv Skin Wound Care. Jan 2010;23(1):34-38. PMID 20101114

53. Harding K, Sumner M, Cardinal M. A prospective, multicentre, randomised controlled study of human fibroblast-derived dermal substitute (Dermagraft) in patients with venous leg ulcers. Int Wound J. Apr 2013;10(2):132-137. PMID 23506344

54. Cazzell S. A Randomized Controlled Trial Comparing a Human Acellular Dermal Matrix Versus Conventional Care for the Treatment of Venous Leg Ulcers. Wounds, 2019 Feb 6;31(3). PMID 30720443

55. Carsin H, Ainaud P, Le Bever H, et al. Cultured epithelial autografts in extensive burn coverage of severely traumatized patients: a five-year single-center experience with 30 patients. Burns. Jun 2000;26(4):379-387. PMID 10751706

56. Lagus H, Sarlomo-Rikala M, Bohling T, et al. Prospective study on burns treated with Integra(R), a cellulose sponge and split-thickness skin graft: comparative clinical and histological study--randomized controlled trial. Burns. Dec 2013;39(8):1577-1587. PMID 23880091

57. Branski LK, Herndon DN, Pereira C, et al. Longitudinal assessment of Integra in primary burn management: a randomized pediatric clinical trial. Crit Care Med. Nov 2007;35(11):2615-2623. PMID 17828040

58. Heimbach DM, Warden GD, Luterman A, et al. Multicenter postapproval clinical trial of Integra dermal regeneration template for burn treatment. J Burn Care Rehabil. Jan-Feb 2003;24(1):42-48. PMID 12543990

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59. Lukish JR, Eichelberger MR, Newman KD, et al. The use of a bioactive skin substitute decreases length of stay for pediatric burn patients. J Pediatr Surg. Aug 2001;36(8):1118-1121. PMID 11479839

60. Amani H, Dougherty WR, Blome-Eberwein S. Use of Transcyte and dermabrasion to treat burns reduces length of stay in burns of all size and etiology. Burns. Nov 2006;32(7):828-832. PMID 16997480

61. Fivenson DP, Scherschun L, Cohen LV. Apligraf in the treatment of severe mitten deformity associated with recessive dystrophic epidermolysis bullosa. Plast Reconstr Surg. Aug 2003;112(2):584-588. PMID 12900618

62. Baldursson BT, Kjartansson H, Konradsdottir F, et al. Healing rate and autoimmune safety of full-thickness wounds treated with fish skin acellular dermal matrix versus porcine small intestine submucosa: a noninferiority study. Int J Low Extrem Wounds. Mar 2015;14(1):37-43. PMID 25759413

63. Still J, Glat P, Silverstein P, et al. The use of a collagen sponge/living cell composite material to treat donor sites in burn patients. Burns. Dec 2003;29(8):837-841. PMID 14636761

64. Brown-Etris M, Milne CT, Hodde JP. An extracellular matrix graft (Oasis wound matrix) for treating full-thickness pressure ulcers: A randomized clinical trial. J Tissue Viability, 2018 Dec 5;28(1). PMID 30509850

65. Lazic T, Falanga V. Bioengineered skin constructs and their use in wound healing. Plast Reconstr Surg. Jan 2011;127 Suppl 1:75S-90S. PMID 21200276

66. Saffle JR. Closure of the excised burn wound: temporary skin substitutes. Clin Plast Surg. Oct 2009;36(4):627-641. PMID 19793557

67. National Institute for Health and Care Excellence (NICE). Diabetic Foot Problems: Prevention and Management [NG19]. 2019; https://www.nice.org.uk/guidance/ng19/evidence . Accessed March 2020.

68. Centers for Medicare & Medicaid Services (CMS). Fact Sheet: CMS finalizes Medicare Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System changes for 2019 https://www.cms.gov/newsroom/fact-sheets/cms-finalizes-medicare-hospital-outpatient-prospective-payment-system-and-ambulatory-surgical-center . Accessed March 2020.

69. Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD) for Porcine Skin and Gradient Pressure Dressings (270.5). n.d.; https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=139&ncdver=1&bc=AgAAQAAAAAAA&. Accessed March 2020.

History

Date Comments 09/01/16 New policy, approved August 9, 2016. Add to Surgery section. Some bioengineered

skin and soft tissue substitutes may be considered medically necessary when criteria are met. The use of bioengineered skin and soft tissue substitutes is investigational when criteria are not met. The effective date of this policy is December 1, 2016.

01/06/17 Updated effective date. The effective date of this policy has been updated to March 1, 2017.

02/17/17 Coding update. Added new HCPCS codes Q4166-Q4167 and Q4169-Q4175 with effective date 01/01/17. Removed HCPCS codes Q4137, Q4139, Q4151, and Q4163.

https://www.nice.org.uk/guidance/ng19/evidencehttps://www.cms.gov/newsroom/fact-sheets/cms-finalizes-medicare-hospital-outpatient-prospective-payment-system-and-ambulatory-surgical-centerhttps://www.cms.gov/newsroom/fact-sheets/cms-finalizes-medicare-hospital-outpatient-prospective-payment-system-and-ambulatory-surgical-centerhttps://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=139&ncdver=1&bc=AgAAQAAAAAAA&https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=139&ncdver=1&bc=AgAAQAAAAAAA&

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Date Comments 04/01/17 Annual Review, approved March 14, 2017. Policy updated with literature review

through November 7, 2016; references 6, 19, 26, and 28-29 added; rationale revised and some references removed. Investigational products list updated: Microderm, TruSkin products added; MatriStem renamed Cytal; FortaDerm renamed PuraPly; Unite Biomatrix deleted (no longer available). AlloMend added to medically necessary statement for breast reconstructive surgery. AlloPatch added to medically necessary statement for diabetic lower-extremity ulcers. Criteria for human amniotic membrane products for diabetic foot ulcers moved to policy 7.01.149. Section on laryngoplasty removed. Coding updated, removed HCPCS codes Q4119-Q4120 and Q4129 as they terminated as of 1/1/17. CPT code table removed.

06/20/17 Coding update, removed HCPCS codes Q4148, Q4155, and Q4156 as they are applicable to policy 7.01.149.

08/09/17 Coding update, removed HCPCS codes Q4131-Q4133, Q4145, and Q4154 from policy as they are addressed on a separate medical policy. Moved HCPCS codes Q4104 and Q4108 from investigational to medically necessary.

11/01/17 Interim Review, approved October 10, 2017.CellerateRX® (CRXa™) and Integra® Omnigraft™ Dermal Regeneration Matrix removed from the investigational policy statement, may be considered medically necessary if criteria are met. The Evidence Review section was reformatted.

12/01/17 Minor update; added DermACELL® which was inadvertently left off of policy.

05/01/18 Annual Review, approved April 3, 2018. Policy updated with literature review through November 2017; references 4-5, 7, 9, 15, 20, 29, 35, and 54 added; references 59 and 61 updated. DermACELL and FlexHD Pliable added to medically necessary statement on breast reconstructive surgery. Integra Flowable Wound Matrix added to medically necessary statement on use of Integra Dermal Regeneration Template for diabetic lower-extremity ulcers. Several products added to investigational list.

01/01/19 Coding updated, added new HCPCS codes Q4193, Q4195, Q4196, Q4197, Q4200, Q4201, Q4202, Q4203, and Q4204 new codes effective 1/1/19).

02/01/19 Minor coding updates, Q4102 moved to the “Medically Necessary (Eligible for Coverage)” section. Minor formatting edits.

04/01/19 Annual Review, approved March 19, 2019. Policy updated with literature review through December 2018; references 28 and 43 added. Policy statements unchanged. Added HCPCS codes Q4179 and Q4182 to the “Investigational (Not Eligible for Coverage)” section. Removed HCPCS codes Q4138, Q4140, Q4153, Q4157, Q4159, Q4160, Q4169-Q4171, Q4173, Q4174, Q4201, and Q4202.

01/01/20 Coding update, removed HCPCS code Q4172 as it was terminated 1/1/19.

03/01/20 Coding update, removed HCPCS code Q4150 and Q4204 as they are applicable to a separate policy. Added HCPCS codes A6460 and A6461. Added new HCPCS codes Q4220, Q4222, and Q4226 (new codes effective 10/1/19).

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Date Comments 04/01/20 Annual Review, approved March 3, 2020. Policy updated with literature review through

November 2019; references added. Policy statements unchanged.

06/25/2020 Coding update. Added HCPCS code Q4238 under investigative section.

Disclaimer: This medical policy is a guide in evaluating the medical necessity of a particular service or treatment. The Company adopts policies after careful review of published peer-reviewed scientific literature, national guidelines and local standards of practice. Since medical technology is constantly changing, the Company reserves the right to review and update policies as appropriate. Member contracts differ in their benefits. Always consult the member benefit booklet or contact a member service representative to determine coverage for a specific medical service or supply. CPT codes, descriptions and materials are copyrighted by the American Medical Association (AMA). ©2020 Premera All Rights Reserved.

Scope: Medical policies are systematically developed guidelines that serve as a resource for Company staff when determining coverage for specific medical procedures, drugs or devices. Coverage for medical services is subject to the limits and conditions of the member benefit plan. Members and their providers should consult the member benefit booklet or contact a customer service representative to determine whether there are any benefit limitations applicable to this service or supply. This medical policy does not apply to Medicare Advantage.

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Getting Help in Other Languages

This Notice has Important Information. This notice may have important information about your application or coverage through Premera Blue Cross. There may be key dates in this notice. You may need to take action by certain deadlines to keep your health coverage or help with costs. You have the right to get this information and help in your language at no cost. Call 800-722-1471 (TTY: 800-842-5357).

አማሪኛ (Amharic): ይህ ማስታወቂያ አስፈላጊ መረጃ ይዟል። ይህ ማስታወቂያ ስለ ማመልከቻዎ ወይም የ Premera Blue Cross ሽፋን አስፈላጊ መረጃ ሊኖረው ይችላል። በዚህ ማስታወቂያ ውስጥ ቁልፍ ቀኖች ሊኖሩ ይችላሉ። የጤናን ሽፋንዎን ለመጠበቅና በአከፋፈል እርዳታ ለማግኘት በተውሰኑ የጊዜ ገደቦች እርምጃ መውሰድ ይገባዎት ይሆናል። ይህን መረጃ እንዲያገኙ እና ያለምንም ክፍያ በቋንቋዎ እርዳታ እንዲያገኙ መብት አለዎት።በስልክ ቁጥር 800-722-1471 (TTY: 800-842-5357) ይደውሉ።

( ةالعربي :(. امةھ ماتولعم اإلشعار ھذا يحوي

خالل من ھاعلي صولحلا تريد لتيا التغطيةلل أو ةصحيلاكطيتتغ لىع اظلحفل نةعيم يخراوت في إجراء خاذتال تحتاج وقد .اإلشعار ھذا في

تكلفة أية بدتك دون بلغتك مساعدةوال تاوملالمع ھذه على ولحصال لك يحق .800-722-1471 (TTY: 800-842-5357)

أو طلبك وصخصب مةمھ ماتوعلم عارشإلا ھذا ويحي قدةمھم يخراوت ھناك تكون قد .Premera Blue Cross

اعدةمس تصلايفكالتال دفع فيبـ

.

Arabic

Oromoo (Cushite): Beeksisni kun odeeffannoo barbaachisaa qaba. Beeksisti kun sagantaa yookan karaa Premera Blue Cross tiin tajaajila keessan ilaalchisee odeeffannoo barbaachisaa qabaachuu danda’a. Guyyaawwan murteessaa ta’an beeksisa kana keessatti ilaalaa. Tarii kaffaltiidhaan deeggaramuuf yookan tajaajila fayyaa keessaniif guyyaa dhumaa irratti wanti raawwattan jiraachuu danda’a. Kaffaltii irraa bilisa haala ta’een afaan keessaniin odeeffannoo argachuu fi deeggarsa argachuuf mirga ni qabaattu. Lakkoofsa bilbilaa 800-722-1471 (TTY: 800-842-5357) tii bilbilaa.

Français (French): Cet avis a d'importantes informations. Cet avis peut avoir d'importantes informations sur votre demande ou la couverture par l'intermédiaire de Premera Blue Cross. Le présent avis peut contenir des dates clés. Vous devrez peut-être prendre des mesures par certains délais pour maintenir votre couverture de santé ou d'aide avec les coûts. Vous avez le droit d'obtenir cette information et de l’aide dans votre langue à aucun coût. Appelez le 800-722-1471 (TTY: 800-842-5357).

Kreyòl ayisyen (Creole): Avi sila a gen Enfòmasyon Enpòtan ladann. Avi sila a kapab genyen enfòmasyon enpòtan konsènan aplikasyon w lan oswa konsènan kouvèti asirans lan atravè Premera Blue Cross. Kapab genyen dat ki enpòtan nan avi sila a. Ou ka gen pou pran kèk aksyon avan sèten dat limit pou ka kenbe kouvèti asirans sante w la oswa pou yo ka ede w avèk depans yo. Se dwa w pou resevwa enfòmasyon sa a ak asistans nan lang ou pale a, san ou pa gen pou peye pou sa. Rele nan 800-722-1471 (TTY: 800-842-5357).

Deutsche (German): Diese Benachrichtigung enthält wichtige Informationen. Diese Benachrichtigung enthält unter Umständen wichtige Informationen bezüglich Ihres Antrags auf Krankenversicherungsschutz durch Premera Blue Cross. Suchen Sie nach eventuellen wichtigen Terminen in dieser Benachrichtigung. Sie könnten bis zu bestimmten Stichtagen handeln müssen, um Ihren Krankenversicherungsschutz oder Hilfe mit den Kosten zu behalten. Sie haben das Recht, kostenlose Hilfe und Informationen in Ihrer Sprache zu erhalten. Rufen Sie an unter 800-722-1471 (TTY: 800-842-5357).

Hmoob (Hmong): Tsab ntawv tshaj xo no muaj cov ntshiab lus tseem ceeb. Tej zaum tsab ntawv tshaj xo no muaj cov ntsiab lus tseem ceeb txog koj daim ntawv thov kev pab los yog koj qhov kev pab cuam los ntawm Premera Blue Cross. Tej zaum muaj cov hnub tseem ceeb uas sau rau hauv daim ntawv no. Tej zaum koj kuj yuav tau ua qee yam uas peb kom koj ua tsis pub dhau cov caij nyoog uas teev tseg rau hauv daim ntawv no mas koj thiaj yuav tau txais kev pab cuam kho mob los yog kev pab them tej nqi kho mob ntawd. Koj muaj cai kom lawv muab cov ntshiab lus no uas tau muab sau ua koj hom lus pub dawb rau koj. Hu rau 800-722-1471 (TTY: 800-842-5357).

Iloko (Ilocano): Daytoy a Pakdaar ket naglaon iti Napateg nga Impormasion. Daytoy a pakdaar mabalin nga adda ket naglaon iti napateg nga impormasion maipanggep iti apliksayonyo wenno coverage babaen iti Premera Blue Cross. Daytoy ket mabalin dagiti importante a petsa iti daytoy a pakdaar. Mabalin nga adda rumbeng nga aramidenyo nga addang sakbay dagiti partikular a naituding nga aldaw tapno mapagtalinaedyo ti coverage ti salun-atyo wenno tulong kadagiti gastos. Adda karbenganyo a mangala iti daytoy nga impormasion ken tulong iti bukodyo a pagsasao nga awan ti bayadanyo. Tumawag iti numero nga 800-722-1471 (TTY: 800-842-5357).

Italiano ( ):Questo avviso contiene informazioni importanti. Questo avviso può contenere informazioni importanti sulla tua domanda o copertura attraverso Premera Blue Cross. Potrebbero esserci date chiave in questo avviso. Potrebbe essere necessario un tuo intervento entro una scadenza determinata per consentirti di mantenere la tua copertura o sovvenzione. Hai il diritto di ottenere queste informazioni e assistenza nella tua lingua gratuitamente. Chiama 800-722-1471 (TTY: 800-842-5357).

Italian

中文 (Chinese):本通知有重要的訊息。本通知可能有關於您透過 Premera Blue Cross 提交的申請或保險的重要訊息。本通知內可能有重要日期。您可能需要在截止日期

之前採取行動，以保留您的健康保險或者費用補貼。您有權利免費以您的母

語得到本訊息和幫助。請撥電話 800-722-1471 (TTY: 800-842-5357)。

037338 (07-2016)

https://www.hhs.gov/ocr/office/file/index.htmlhttps://ocrportal.hhs.gov/ocr/portal/lobby.jsfmailto:AppealsDepartmentInquiries@Premera.com

日本語 (Japanese):この通知には重要な情報が含まれています。この通知には、 Premera Blue Crossの申請または補償範囲に関する重要な情報が含まれている場合があります。この通知に記載されている可能性がある重要な日付をご確認くだ

さい。健康保険や有料サポートを維持するには、特定の期日までに行動を

取らなければならない場合があります。ご希望の言語による情報とサポー

トが無料で提供されます。800-722-1471 (TTY: 800-842-5357)までお電話ください。

한국어 (Korean): 본 통지서에는 중요한 정보가 들어 있습니다 . 즉 이 통지서는 귀하의 신청에 관하여 그리고 Premera Blue Cross 를 통한 커버리지에 관한 정보를 포함하고 있을 수 있습니다 . 본 통지서에는 핵심이 되는 날짜들이 있을 수 있습니다. 귀하는 귀하의 건강 커버리지를 계속 유지하거나 비용을 절감하기 위해서 일정한 마감일까지 조치를 취해야 할 필요가 있을 수 있습니다 . 귀하는 이러한 정보와 도움을 귀하의 언어로 비용 부담없이 얻을 수 있는 권리가 있습니다 . 800-722-1471 (TTY: 800-842-5357) 로 전화하십시오 .

ລາວ (Lao): ແຈ້ງການນີ້ ນສໍ າຄັນ. ແຈ້ງການນີ້ອາດຈະມີ ນສໍ າຄັນກ່ຽວກັບຄໍ າຮ້ອງສະ ກ ຫຼື ຄວາມຄຸ້ມຄອງປະກັນໄພຂອງທ່ານຜ່ານ Premera Blue Cross. ອາດຈະມີ ນທີ າຄັນໃນແຈ້ງການນີ້. ທ່ານອາດຈະຈໍ າເປັ ນຕ້ອງດໍ າເນີ ນການຕາມກໍ ານົດ ເວລາສະເພາະເພື່ອຮັກສາຄວາມຄຸ້ມຄອງປະກັນສຸຂະພາບ ຫຼື ຄວາມຊ່ວຍເຫຼື ອເລື່ອງ າໃຊ້ າຍຂອງທ່ານໄວ້ . ທ່ານມີ ດໄດ້ ບຂໍ້ ນນີ້ ແລະ ຄວາມຊ່ວຍເຫຼື ອເປັ ນພາສາ ຂອງທ່ານໂດຍບ່ໍ ເສຍຄ່າ. ໃຫ້ໂທຫາ 800-722-1471 (TTY: 800-842-5357).

ູຂໍ້

່

ສໍ ັ

ຈ

ໝ

ສິ

ັ

່

ວ

ຄ

ມ

ມູຮັ

ູມີ ມຂໍ້

ភាសាែខមរ ( ): ឹ

រងរបស់

Premera Blue Cross ។ របែហលជាមាន កាលបរ ិ ឆ ំខានេនៅកងេសចក

េសចកតជី ូ

ជាមានព័ ៌ ៉ ងសំ ់អពី ់ ៉ ប់

នដំ ងេនះមានព័ ី

តមានយា ខាន ំ ទរមងែបបបទ ឬការរា

ណ ត៌មានយ៉ា ំ ់ តងសខាន។ េសចក

េចទស ់ ន ុ ត

ណងេនះ។ អ វការបេញញសមតភាព ដលកណតៃថ ចបាស

កតាមរយៈ

ដំ ឹ នករបែហលជារតូ ច ថ ់ ំ ់ ងជាក់ ់

នដ

ន

ី ន

ូ

អ

ូ

ជ

ជ

ំណឹងេនះរបែហល

នានា េដើ ីនងរកសាទុ ៉ បរងស់ ុ ់ ក ឬរបាក់ ំ

អ

មប ឹ កការធានារា ខភាពរបស ជ

ធនកមានសិ ទទលព័ មានេនះ និ ំ យេនៅកុងភាសារបសទិ ួ ត៌ ងជ ននួ

ន

់ កេដាយម

អ

នអ

យេចញៃថល។ ួ

នអស

ន

ិ

លុ ើ ូ ូយេឡយ។ សមទ ទ រស័ព 800-722-1471 (TTY: 800-842-5357)។

Khmer

ਕਵਰਜ ਅਤ ਅਰਜੀ ਬਾਰ ਮਹ ਤਵਪਰਨ ਜਾਣਕਾਰੀ ਹ ਸਕਦੀ ਹ . ਇਸ ਨ ਿਜਸ ਜਵਚ ਖਾਸ

ਤਾਰੀਖਾ ਹ ਸਕਦੀਆ ਹਨ. ਜੇਕਰ ਤਸੀ ਜਸਹਤ ਕਵਰਜ ਿਰਖਣੀ ਹਵ ਜਾ ਓਸ ਦੀ ਲਾਗਤ ਜਿਵਚ ਮਦਦ ਦ ੇਇਛ ੁਕ ਹ ਤਾਂ ਤਹਾਨ ਅ ਤਮ ਤਾਰੀਖ਼ ਤ ਪਿਹਲਾਂ ਕੁ ਝ ਖਾਸ ਕਦਮ ਚ ਕਣ ਦੀ ਲੜ ਹ ਸਕਦੀ ਹ ,ਤਹੁਾਨ ਮਫ਼ਤ ਿਵਚ ਤ ਆਪਣੀ ਭਾਸ਼ਾ ਿਵ ਚ ਜਾਣਕਾਰੀ ਅਤ ਮਦਦ ਪਾਪਤ ਕਰਨ ਦਾ ਅਿਧਕਾਰ ਹ ,ਕਾਲ 800-722-1471 (TTY: 800-842-5357).

ਪ ਜਾਬੀ (Punjabi): ਇਸ ਨ ਿਟਸ ਿਵਚ ਖਾਸ ਜਾਣਕਾਰੀ ਹ. ਇਸ ਨ ਿਟਸ ਿਵਚ Premera Blue Cross ਵਲ ਤੁਹਾਡੀ

ੰ

ੰ

ੇ ੇ ੇ ੱ ੂ ੋ ੈ ੋੋ ਂ ੁ ੇ ੱ ੋ ੇ ੱੱ ੁ ੱ ੂੁ ੱ ੇ ੱ ੇ ੍ਰ ੈ

ੋ ੰ ੂ ੱ ੁ ੋ ੋ ੈ ੰ

ੋ ੈ ੋ

(Farsi): فارسی فرم بارهدر ھمم اطالعات حاوی است ممکن يهمالعا اين. ميباشد ھمم اطالعات یوحا يهمالعا اين

در ھمم ھای خيتار به باشد.پ رایبستاکنممماش زينهھ اختدپر در مککيا تان بيمهوشش حقظ

Premera Blue Cross طريق از ماش مهبيوشش يا و تقاضا ای پ. يدماين جهتو يهمالعا اين

حق شما. يدشاب داشته اجتياح صیاخ کارھای امانج برای صیمشخ ایھ خيتار به تان، انیمدر ھای کسب برای .نماييد دريافت گانيرا ورط به ودخ زبان به را کمک و اطالعات اين که داريد را اين

استم ) 5357-842-800 مارهباش ماست TTY انکاربر(800-722-1471 مارهش با اطالعات .اييدنم برقرار

้

Polskie (Polish): To ogłoszenie może zawierać ważne informacje. To ogłoszenie może

zawierać ważne informacje odnośnie Państwa wniosku lub zakresu świadczeń poprzez Premera Blue Cross. Prosimy zwrócic uwagę na kluczowe daty, które mogą być zawarte w tym ogłoszeniu aby nie przekroczyć terminów w przypadku utrzymania polisy ubezpieczeniowej lub pomocy związanej z kosztami. Macie Państwo prawo do bezpłatnej informacji we własnym języku. Zadzwońcie pod 800-722-1471 (TTY: 800-842-5357).

Português (Portuguese): Este aviso contém informações importantes. Este aviso poderá conter informações importantes a respeito de sua aplicação ou cobertura por meio do Premera Blue Cross. Poderão existir datas importantes neste aviso. Talvez seja necessário que você tome providências dentro de determinados prazos para manter sua cobertura de saúde ou ajuda de custos. Você tem o direito de obter e sta informação e ajuda em seu idioma e sem custos. Ligue para 800-722-1471 (TTY: 800-842-5357).

Română (Romanian): Prezenta notificare conține informații importante. Această notificare poate conține informații importante privind cererea sau acoperirea asigurării dumneavoastre de sănătate prin Premera Blue Cross. Pot exista date cheie în această notificare. Este posibil să fie nevoie să acționați până la anumite termene limită pentru a vă menține acoperirea asigurării de sănătate sau asistența privitoare la costuri. Aveți dreptul de a obține gratuit aceste informații și ajutor în limba dumneavoastră. Sunați la 800-722-1471 (TTY: 800-842-5357).

Pусский (Russian): Настоящее уведомление содержит важную информацию. Это уведомление может содержать важную информацию о вашем заявлении или страховом покрытии через Premera Blue Cross. В настоящем уведомлении могут быть указаны ключевые даты. Вам, возможно, потребуется принять меры к определенным предельным срокам для сохранения страхового покрытия или помощи с расходами. Вы имеете право на бесплатное получение этой информации и помощь на вашем языке. Звоните по телефону 800-722-1471 (TTY: 800-842-5357).

Fa’asamoa (Samoan): Atonu ua iai i lenei fa’asilasilaga ni fa’amatalaga e sili ona taua e tatau ona e malamalama i ai. O lenei fa’asilasilaga o se fesoasoani e fa’amatala atili i ai i le tulaga o le polokalame, Premera Blue Cross, ua e tau fia maua atu i ai. Fa’amolemole, ia e iloilo fa’alelei i aso fa’apitoa olo’o iai i lenei fa’asilasilaga taua. Masalo o le’a iai ni feau e tatau ona e faia ao le’i aulia le aso ua ta’ua i lenei fa’asilasilaga ina ia e iai pea ma maua fesoasoani mai ai i le polokalame a le Malo olo’o e iai i ai. Olo’o iai iate oe le aia tatau e maua atu i lenei fa’asilasilaga ma lenei fa’matalaga i legagana e te malamalama i ai aunoa ma se togiga tupe. Vili atu i le telefoni 800-722-1471 (TTY: 800-842-5357).

Español ( ): Este Aviso contiene información importante. Es posible que este aviso contenga información importante acerca de su solicitud o cobertura a través de Premera Blue Cross. Es posible que haya fechas clave en este

tiene derecho a recibir esta información y ayuda en su idioma sin costo

aviso. Es posible que deba tomar alguna medida antes de determinadas fechas para mantener su cobertura médica o ayuda con los costos. Usted

alguno. Llame al 800-722-1471 (TTY: 800-842-5357).

Spanish

Tagalog (Tagalog): Ang Paunawa na ito ay naglalaman ng mahalagang impormasyon. Ang paunawa na ito ay maaaring naglalaman ng mahalagang impormasyon tungkol sa iyong aplikasyon o pagsakop sa pamamagitan ng Premera Blue Cross. Maaaring may mga mahalagang petsa dito sa paunawa. Maaring mangailangan ka na magsagawa ng hakbang sa ilang mga itinakdang panahon upang mapanatili ang iyong pagsakop sa kalusugan o tulong na walang gastos. May karapatan ka na makakuha ng ganitong impormasyon at tulong sa iyong wika ng walang gastos. Tumawag sa 800-722-1471 (TTY: 800-842-5357).

ไทย (Thai): ประกาศนมขอมลสาคญ ประกาศนอาจมขอมลทสาคญเกยวกบการการสมครหรอขอบเขตประกน สขภาพของคณผาน Premera Blue Cross และอาจมกาหนดการในประกาศน คณอาจจะตอง ดาเนนการภายในกาหนดระยะเวลาทแนนอนเพอจะรกษาการประกนสขภาพของคณหรอการชวยเหลอท มคาใชจาย คณมสทธทจะไดรบขอมลและความชวยเหลอนในภาษาของคณโดยไม่มคาใชจาย โทร 800-722-1471 (TTY: 800-842-5357)

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Український (Ukrainian): Це повідомлення містить важливу інформацію. Це повідомлення може містити важливу інформацію про Ваше звернення щодо страхувального покриття через Premera Blue Cross. Зверніть увагу на ключові дати, які можуть бути вказані у цьому повідомленні. Існує імовірність того, що Вам треба буде здійснити певні кроки у конкретні кінцеві строки для того, щоб зберегти Ваше медичне страхування або отримати фінансову допомогу. У Вас є право на отримання цієї інформації та допомоги безкоштовно на Вашій рідній мові. Дзвоніть за номером телефону 800-722-1471 (TTY: 800-842-5357).

Tiếng Việt (Vietnamese): Thông báo này cung cấp thông tin quan trọng. Thông báo này có thông tin quan trọng về đơn xin tham gia hoặc hợp đồng bảo hiểm của quý vị qua chương trình Premera Blue Cross. Xin xem ngày quan trọng trong thông báo này. Quý vị có thể phải thực hiện theo thông báo đúng trong thời hạn để duy trì bảo hiểm sức khỏe hoặc được trợ giúp thêm về chi phí. Quý vị có quyền được biết thông tin này và được trợ giúp bằng ngôn ngữ của mình miễn phí. Xin gọi số 800-722-1471 (TTY: 800-842-5357).