MEDICAL POLICY – 9.01.511 Surgical Dressings and Wound Care Supplies Ref. Policy: MP-011 Effective Date: Oct. 1, 2020 Last Revised: Sept. 17, 2020 Replaces: N/A

RELATED MEDICAL POLICIES: 1.01.529 Durable Medical Equipment

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

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Introduction

Surgical or wound care dressings are used after surgery to help control bleeding, prevent infection, and promote healing. This policy describes when specific surgical dressings and wound care supplies may be considered 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

Service Medical Necessity Surgical dressings and wound care supplies

Surgical dressings and wound care supplies may be considered medically necessary when all of the following general and specific guidelines are met: • General guidelines

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Service Medical Necessity o Surgical or wound care dressings are used for wound

debridement or the treatment of a wound caused by, or treated by, a surgical procedure

o Dressing supplies are ordered by the treating physician and provided by a home care agency or a surgical supply vendor

o Medical necessity is documented in the patient’s medical record to support dressing changes if they are more frequent than recommended in the guidelines listed in this policy

Note: An order for each item billed must be signed and dated by the treating

physician, kept on file by the supplier, and made available.

• Specific guidelines o Alginate or other fiber gelling dressing – Covered (A6196-

A6199) Moderately to highly exudative full thickness wounds

(eg, stage III or IV ulcers), and alginate or other fiber gelling dressing fillers for moderately to highly exudative full thickness wound cavities (eg, stage III or IV ulcers) to maintain a moist environment on the wound base (ie, Aquacel, Algisite, Silvercel, Nu-Derm Aliginate)

One wound cover sheet of the approximate size of the wound or up to two units of wound filler (one unit = six inches of alginate or other fiber gelling dressing rope) is usually used at each dressing change

Usual dressing change is up to once per day o Collagen-based dressings – Covered (A6010-A6011, A6021-

A6024) Collagen dressings are high in absorptive capabilities.

They provide strength, elasticity, and structure to tissue (ie, Cellerate Gel, Puracol, Biostep, Fibracol, Prisma, Promogran).

o Composite dressing – Covered (A6203-A6204)

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Service Medical Necessity A single dressing that provides multiple functions. As a

bacterial barrier, an absorptive layer other than an alginate, foam, hydrocolloid, or hydrogel, as either a semi-adherent or non-adherent property over the wound site, and an adhesive border (ie, Covaderm Plus, Mepore Pro, Opsite Post-op, Stratasob).

Up to three composite dressing changes per week are considered medically necessary, one wound cover per dressing change and usual composite dressing change is up to three times per week.

o Compression burn garments - Covered (A6501-A6513) Used to reduce hypertrophic scarring and joint

contractures following a burn injury o Contact layers - Covered (A6206-A6208) Dressings which are porous thin non-adherent sheets

placed directly on an open wound or to line a wound Placed directly on an open wound bed to protect the

wound tissue from direct contact with other agents Usual dressing change is up to once per week

o Dressing over a percutaneous catheter or tube - Covered As long as the catheter or tube remains in place and

after removal until the wound heals o Foam dressing – Covered (A6029-A6215) A sterile, non-linting, absorptive non-adherent dressing Used on full thickness wounds (eg, stage III or IV ulcers)

with moderate to heavy exudate (ie, Tegaderm, Polymem, Lyofoam, Mepi Lex, Allevyn, Tielle)

When used as a primary or secondary dressing, the usual dressing change is up to three times per week

Usual dressing change for foam wound fillers is up to one per day

o Gauze, impregnated with water or normal saline (Refer to Limitations section)

o Gauze, impregnated with other than water or normal saline – Covered (A6222-A6224, A6231-A6233, A6266, A6456)

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Service Medical Necessity Up to one dressing change per day for gauze dressings

impregnated with other than water or normal saline (ie, Kerlix AMD, Telfa AMD, Petrolatum gauze, Xeroform)

o Gauze, non-impregnated – Covered (A6216-A6221, A6402-A6404, A6407, A6457) For a dressing without a border – up to three dressing

changes per day are covered For a dressing with a border – one dressing change per

day is covered

Note: It is usually not considered medically necessary to stack more than two gauze pads on top of each other in any one area.

o Gradient compression garments/stockings – Covered Non-elastic gradient compression wrap is limited to one

every six months o Hydrocolloid dressing – Covered (A6234-A6241) Used on wounds with light to moderate exudate to

provide a moist healing environment and help to stimulate and protect any newly formed tissue (ie, Tegaderm, Comfeel, Flexicol, Combiderm, Duoderm, NuDerm Hydrocolloid)

Up to three dressing changes per week are covered for hydrocolloid wound covers or hydrocolloid wound fillers

o Hydrogel dressing – Covered (A6242-A6248) Used on full thickness wounds with minimal or no

exudate (eg, stage III or IV ulcers). They offer a “cooling” effect, act as a barrier, and provide a moist healing environment ie, Avogel, Dermagel, NuGel).

The usual dressing change for hydrogel wound covers without adhesive border or hydrogel wound fillers is up to once per day.

The usual dressing change for hydrogel wound covers with adhesive border is up to three times per week.

o Non-elastic gradient compression wrap – Covered (A6545) Used in the treatment of open venous stasis ulcer

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Service Medical Necessity o Other (light compression bandage, moderate/high

compression bandage, self-adherent bandage, conforming bandage, padded bandage, eye pad, surgical dressing holder, misc. – A4461, A4463, A4649, A6410-A6412, A6441-A6455) Light compression, self-adherent bandage and

conforming bandages – Covered They are used to hold wound cover dressings in

place over any wound type The usual frequency of changing these bandages is

once per week unless they are part of a multi-layer compression bandage system

Moderate/high compression bandages, conforming bandages, self-adherent bandages and padded bandages – Covered They are part of a multi-layer compression bandage

system used in the treatment of venous stasis ulcer The usual frequency of these bandages is once per

week unless they are part of a multi-layer compression bandage system

Conforming bandage dressing The dressing change is determined by the frequency

of change of the underlying dressing o Silver dressings – Refer to the indications for other

components of the dressing (eg, foam, non-impregnated gauze dressing etc.)

o Specialty bbsorptive dressing – Covered (A6251-A6256) Unitized as multi-layer dressings which provide either a

semi-adherent quality or non-adherent layer, and are made of highly absorptive layers of fibers such as absorbent cellulose, cotton, or rayon, with/without adhesive border

Used for moderately or highly exudative wounds (eg, stage III or IV ulcers)

Up to one dressing change of specialty absorptive dressing per day is covered for a dressing without an adhesive border

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Service Medical Necessity Up to one dressing change every other day for a

dressing with an adhesive border o Surgical dressings – Covered o Surgical dressings used in conjunction with investigational

wound healing (eg, platelet derived wound healing formula) – Covered When all applicable coverage criteria are met based on

the number and type of surgical dressings that are appropriate to treat the wound if the investigational therapy were not being used.

o Tape – Covered (A4450, A4452) Used to hold on a wound cover, elastic roll gauze or

non-elastic roll gauze. The usual use for wound covers measuring 16 square

inches or less is up to two units per dressing change The usual use for wound covers measuring 16 to 48

square inches is up to three units per dressing change The usual use for wound covers measuring greater than

48 square inches, up to four units per dressing change Additional tape is usually not required when a wound

cover with an adhesive border is used. The medical necessity for tape in these situations would need to be documented.

The medically necessary frequency of tape change is determined by the frequency of change of the wound cover

o Transparent film dressings – Covered (A6257-A6259) Used on open partial thickness wounds with minimal

exudate or closed wounds (ie, Tegaderm, Polyskin, Opsite Flexigrid)

Usual dressing change is up to three times per week o Wound cover with/without adhesive border on all sides –

Covered Flat dressing pads: an adhesive border is usually more

binding than that obtained with separate taping and is therefore indicated for use with wounds requiring less

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Service Medical Necessity frequent dressing changes. When these are being used, no other dressing is needed on top of it.

Reasons for use of additional tape must be well documented

o Wound filler/dressing – Covered (A6261, A6262) Dressing materials which are placed into open wounds

to eliminate dead space, absorb exudate, or maintain a moist wound surface. They come in hydrated forms (ie, gels, pastes, etc.), dry forms (ie, granules, powder, beads, etc.) and other forms (ie, rope, spirals, pillows etc.) Examples: Alginate, or other Fiber Gels, Foam,

Hydrocolloid, Hydrogel and Non-impregnated packing strips

The units of service for wound fillers are one gram, one fluid ounce, six inch length, or one yard depending on the product. If the individual product is packaged as a fraction of a unit (eg, 1/2 fluid ounce), determine the units billed by multiplying the number dispensed times the individual product size and rounding to the nearest whole number. For example, if eleven (11) 1/2 oz. tubes of a wound filler are dispensed, bill six units (11 x 1/2 = 5.5; round to 6). The usual dressing change is up to one time per day The quantity of hydrogel filler used for each wound

must not exceed the amount needed to line the surface of the wound. Additional amounts used to fill a cavity are not medically necessary.

Documentation must substantiate the medical necessity for hydrogel filler used in excess of three fluid ounces per wound in thirty days

o Wound pouch – Covered (A6154) A wound pouch is a waterproof collection device with a

drainable port that adheres to the skin around a wound The usual dressing change is up to three times per week

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Service Medical Necessity Note: See Related Information below for Limitations

Coding

Code Description HCPCS – Covered A4450 Tape, non-waterproof, per 18 square inches

A4452 Tape, waterproof, per 18 square inches

A4461 Surgical dressing holder, non-reusable, each

A4463 Surgical dressing holder, reusable, each

A4649 Surgical supply; miscellaneous

A6010 Collagen based wound filler, dry form, sterile, per gram of collagen

A6011 Collagen based wound filler, gel/paste, per gram of collagen

A6021 Collagen dressing, pad size 16 sq. in. or less, each

A6022 Collagen dressing, pad size more than 16 sq. in. but less than or equal to 48 sq. in., each

A6023 Collagen dressing, pad size more than 48 sq. in., each

A6024 Collagen dressing wound filler, sterile, per 6 inches

A6154 Wound pouch, each

A6196 Alginate or other fiber gelling dressing, wound cover, sterile, pad size 16 sq. in. or less, each dressing

A6197 Alginate or other fiber gelling dressing, wound cover, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., each dressing

A6198 Alginate or other fiber gelling dressing, wound cover, sterile, pad size more than 48 sq. in., each dressing

A6199 Alginate or other fiber gelling dressing, wound filler, sterile, per 6 inches

A6203 Composite dressing, sterile, pad size 16 sq. in. or less, with any size adhesive border, each dressing

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Code Description A6204 Composite dressing, sterile, pad size more than 16 sq. in. but less than or equal to 48

sq. in., with any size adhesive border, each dressing

A6205 Composite dressing, sterile, pad size more than 48 sq. in., with any size adhesive border, each dressing

A6206 Contact layer, sterile, 16 sq. in. or less, each dressing

A6207 Contact layer, sterile, more than 16 sq. in. but less than or equal to 48 sq. in., each dressing

A6208 Contact layer, sterile, more than 48 sq. in., each dressing

A6209 Foam dressing, wound cover, sterile, pad size 16 sq. in. or less, without adhesive border, each dressing

A6210 Foam dressing, wound cover, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., without adhesive border, each dressing

A6211 Foam dressing, wound cover, sterile, pad size more than 48 sq. in., without adhesive border, each dressing

A6212 Foam dressing, wound cover, sterile, pad size 16 sq. in. or less, with any size adhesive border, each dressing

A6213 Foam dressing, wound cover, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., with any size adhesive border, each dressing

A6214 Foam dressing, wound cover, sterile, pad size more than 48 sq. in., with any size adhesive border, each dressing

A6215 Foam dressing, wound filler, sterile, per gram

A6216 Gauze, non-impregnated, non-sterile, pad size 16 sq. in. or less, without adhesive border, each dressing

A6217 Gauze, non-impregnated, non-sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., without adhesive border, each dressing

A6218 Gauze, non-impregnated, non-sterile, pad size more than 48 sq. in., without adhesive border, each dressing

A6219 Gauze, non-impregnated, sterile, pad size 16 sq. in. or less, with any size adhesive border, each dressing

A6220 Gauze, non-impregnated, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., with any size adhesive border, each dressing

A6221 Gauze, non-impregnated, sterile, pad size more than 48 sq. in., with any size adhesive border, each dressing

A6222 Gauze, impregnated with other than water, normal saline, or hydrogel, sterile, pad size 16 sq. in. or less, without adhesive border, each dressing

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Code Description A6223 Gauze, impregnated with other than water, normal saline, or hydrogel, sterile, pad size

more than 16 square inches, but less than or equal to 48 square inches, without adhesive border, each dressing

A6224 Gauze, impregnated with other than water, normal saline, or hydrogel, sterile, pad size more than 48 square inches, without adhesive border, each dressing

A6231 Gauze, impregnated, hydrogel, for direct wound contact, sterile, pad size 16 sq. in. or less, each dressing

A6232 Gauze, impregnated, hydrogel, for direct wound contact, sterile, pad size greater than 16 sq. in., but less than or equal to 48 sq. in., each dressing

A6233 Gauze, impregnated, hydrogel for direct wound contact, sterile, pad size more than 48 sq. in., each dressing

A6234 Hydrocolloid dressing, wound cover, sterile, pad size 16 sq. in. or less, without adhesive border, each dressing

A6235 Hydrocolloid dressing, wound cover, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., without adhesive border, each dressing

A6236 Hydrocolloid dressing, wound cover, sterile, pad size more than 48 sq. in., without adhesive border, each dressing

A6237 Hydrocolloid dressing, wound cover, sterile, pad size 16 sq. in. or less, with any size adhesive border, each dressing

A6238 Hydrocolloid dressing, wound cover, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., with any size adhesive border, each dressing

A6239 Hydrocolloid dressing, wound cover, sterile, pad size more than 48 sq. in., with any size adhesive border, each dressing

A6240 Hydrocolloid dressing, wound filler, paste, sterile, per fluid ounce

A6241 Hydrocolloid dressing, wound filler, dry form, sterile, per gram

A6242 Hydrogel dressing, wound cover, sterile, pad size 16 sq. in. or less, without adhesive border, each dressing

A6243 Hydrogel dressing, wound cover, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., without adhesive border, each dressing

A6244 Hydrogel dressing, wound cover, sterile, pad size more than 48 sq. in., without adhesive border, each dressing

A6245 Hydrogel dressing, wound cover, sterile, pad size 16 sq. in. or less, with any size adhesive border, each dressing

A6246 Hydrogel dressing, wound cover, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., with any size adhesive border, each dressing

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Code Description A6247 Hydrogel dressing, wound cover, sterile, pad size more than 48 sq. in., with any size

adhesive border, each dressing

A6248 Hydrogel dressing, wound filler, gel, per fluid ounce

A6251 Specialty absorptive dressing, wound cover, pad size 16 sq. in. or less, without adhesive border, each dressing

A6252 Specialty absorptive dressing, wound cover, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., without adhesive border, each dressing

A6253 Specialty absorptive dressing, wound cover, sterile, pad size more than 48 sq. in., without adhesive border, each dressing

A6254 Specialty absorptive dressing, wound cover, sterile, pad size 16 sq. in. or less, with any size adhesive border, each dressing

A6255 Specialty absorptive dressing, wound cover, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., with any size adhesive border, each dressing

A6256 Specialty absorptive dressing, wound cover, sterile, pad size more than 48 sq. in., with any size adhesive border, each dressing

A6257 Transparent film, sterile, 16 sq. in. or less, each dressing

A6258 Transparent film, more than 16 sq. in. but less than or equal to 48 sq. in., each dressing

A6259 Transparent film, sterile, more than 48 sq. in., each dressing

A6261 Wound filler, gel/paste, per fluid ounce, not elsewhere classified

A6262 Wound filler, dry form, per gram, not elsewhere classified

A6266 Gauze, impregnated, other than water, normal saline, or zinc paste, sterile, any width, per linear yard

A6402 Gauze, non-impregnated, sterile, pad size 16 sq. in. or less, without adhesive border, each dressing

A6403 Gauze, non-impregnated, sterile, pad size more than 16 sq. in., less than or equal to 48 sq. in., without adhesive border, each dressing

A6404 Gauze, non-impregnated, sterile, pad size more than 48 sq. in., without adhesive border, each dressing

A6407 Packing strips, non-impregnated, sterile, up to 2 inches in width, per linear yard

A6410 Eye pad, sterile, each

A6411 Eye pad, non-sterile, each

A6412 Eye patch, occlusive, each

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Code Description A6413 Adhesive bandage, first-aid type, any size, each

A6441 Padding bandage, non-elastic, non-woven/non-knitted, width greater than or equal to three inches and less than five inches, per yard

A6442 Conforming bandage, non-elastic, knitted/woven, non-sterile, width less than three inches, per yard

A6443 Conforming bandage, non-elastic, knitted/woven, non-sterile, width greater than or equal to three inches and less than five inches, per yard

A6444 Conforming bandage, non-elastic, knitted/woven, non-sterile, width greater than or equal to 5 inches, per yard

A6445 Conforming bandage, non-elastic, knitted/woven, sterile, width less than three inches, per yard

A6446 Conforming bandage, non-elastic, knitted/woven, sterile, width greater than or equal to three inches and less than five inches, per yard

A6447 Conforming bandage, non-elastic, knitted/woven, sterile, width greater than or equal to five inches, per yard

A6448 Light compression bandage, elastic, knitted/woven, width less than three inches, per yard

A6449 Light compression bandage, elastic, knitted/woven, width greater than or equal to three inches and less than five inches, per yard

A6450 Light compression bandage, elastic, knitted/woven, width greater than or equal to five inches, per yard

A6451 Moderate compression bandage, elastic, knitted/woven, load resistance of 1.25 to 1.34 foot pounds at 50% maximum stretch, width greater than or equal to three inches and less than five inches, per yard

A6452 High compression bandage, elastic, knitted/woven, load resistance greater than or equal to 1.35 foot pounds at 50% maximum stretch, width greater than or equal to three inches and less than five inches, per yard

A6453 Self-adherent bandage, elastic, non-knitted/non-woven, width less than three inches, per yard

A6454 Self-adherent bandage, elastic, non-knitted/non-woven, width greater than or equal to three inches and less than five inches, per yard

A6455 Self-adherent bandage, elastic, non-knitted/non-woven, width greater than or equal to five inches, per yard

A6456 Zinc paste impregnated bandage, non-elastic, knitted/woven, width greater than or equal to three inches and less than five inches, per yard

A6457 Tubular dressing with or without elastic, any width, per linear yard

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Code Description A6501 Compression burn garment, bodysuit (head to foot), custom fabricated

A6502 Compression burn garment, chin strap, custom fabricated

A6503 Compression burn garment, facial hood, custom fabricated

A6504 Compression burn garment, glove to wrist, custom fabricated

A6505 Compression burn garment, glove to elbow, custom fabricated

A6506 Compression burn garment, glove to axilla, custom fabricated

A6507 Compression burn garment, foot to knee length, custom fabricated

A6508 Compression burn garment, foot to thigh length, custom fabricated

A6509 Compression burn garment, upper trunk to waist including arm openings (vest) custom fabricated

A6510 Compression burn garment, trunk, including arms down to leg openings (leotard) custom fabricated

A6511 Compression burn garment, lower trunk including leg openings (panty), custom fabricated

A6512 Compression burn garment, not otherwise classified

A6513 Compression burn mask, face and/or neck, plastic or equal, custom fabricated

A6545 Gradient compression wrap, non-elastic, below-knee, 30-50 mm hg, each

HCPCS – Not Covered A6025 Gel sheet for dermal or epidermal application, (eg, silicone, hydrogel, other), each

A6228 Gauze, impregnated, water or normal saline, sterile, pad size 16 sq. in. or less, without adhesive border, each dressing

A6229 Gauze, impregnated, water or normal saline, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. In., without adhesive border, each dressing

A6230 Gauze, impregnated, water or normal saline, sterile, pad size more than 48 sq. in., without adhesive border, each dressing

A6250 Skin sealants, protectants, moisturizers, ointments, any type, any size

A6260 Wound cleansers, any type, any size

Note: CPT codes, descriptions and materials are copyrighted by the American Medical Association (AMA). HCPCS codes, descriptions and materials are copyrighted by Centers for Medicare Services (CMS).

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Related Information

Limitations

• Dressing supplies are not covered when they do not require a prescription and can be purchased by the patient over-the-counter or when they are given to the patient as take-home supplies.

• No more than a one month's supply of dressings is considered medically necessary at one time.

• When a physician applies surgical dressings as part of their service, the surgical dressings are considered incidental to the professional services of the health care practitioner and are not separately payable.

• Not covered under the surgical dressings benefit:

o Antibiotic impregnated dressing – this is considered a drug

o Enzymatic debriding agents

o First-aid type adhesive bandage (a wound cover with pad size less than four inches) – this does not meet the definition of a surgical dressing

o Gauze or other dressings used to cleanse or debride a wound but not left in a wound

o Skin sealants or barriers (A6250)

o Small adhesive bandages (Band-Aids etc.) – they are not primarily used for the treatment of wounds.

o Silicone gel sheet used for the treatment of keloids or other scars (A6025) – this does not meet the definition of a surgical dressing

o Topical antiseptics

o Topical antibiotics

o Wound cleansers or irrigating solutions used to moisten gauze (eg, saline)

o When dressings are covered under other benefits, payment for the dressing is included in the allowance for the other code. For example, dressings used with the following:

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Infusion pumps

Ventricular assist device (VAD)

Parenteral nutrition

Gastrostomy tubes

Tracheostomies

Dialysis catheter

Non-elastic binder

• The following are situations in which dressings/wound care supplies are considered not medically necessary:

o Drainage from a cutaneous fistula which has not been caused by or treated by a surgical procedure

o A stage I pressure ulcer

o A first degree burn

o Wounds caused by trauma which do not require surgical closure or debridement (eg, skin tear or abrasion)

o A venipuncture or arterial puncture site (eg, blood sample) other than the site of an indwelling catheter or needle

• Specific dressings and wound care products that are not medically necessary:

o Alginate or other fiber gelling dressing covers for dry wounds or wounds covered with eschar. It is usually inappropriate to use alginates in combination with hydrogels.

o Elastic stockings, support hose, foot coverings, leotards, knee supports, and surgical leggings, are examples of items that are not ordinarily covered as surgical dressings

o Elastic bandages when used for strains, sprains, edema, or situations other than as a secondary surgical dressing

o Hydrogel dressings used for stage II ulcers. Documentation must substantiate the medical necessity for use of hydrogel dressings for stage II ulcers (eg, location of ulcer is sacro-coccygeal area).

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o Use of both hydrogel filler and hydrogel cover on the same wound at the same time is considered not medically necessary.

o Gauze impregnated with water or normal saline (A6628-A6230) – There is no medical necessity for these dressings compared to non-impregnated gauze which is moistened with bulk saline or sterile water, and therefore these are not covered.

Evidence Review

Background

Surgical dressings referred to in this policy are intended for the use of wound debridement, or the treatment of a wound caused or treated by a surgical procedure. Wound care involves the evaluation and treatment of a wound, including identifying potential causes of delayed wound healing and the modification of treatment when indicated.

The Centers for Medicare and Medicaid Services (CMS) states that the quantity and type of dressings dispensed at any one time must take into account the current status of the wound(s), the likelihood of change, and the recent use of dressings. Dressing needs may change frequently (eg, weekly) in the early phases of wound treatment and/or with heavily draining wounds. Suppliers are also expected to have a mechanism for determining the quantity of dressings that the patient is actually using and to adjust their provision of dressings accordingly. Additionally, surgical dressings must be tailored to the specific needs of an individual patient.

Typically the goal of wound management is that wound care will eventually be able to be performed by the patient (or patient’s caregiver) with supplemental physician assessment and supervision.

References

1. Centers for Medicare and Medicaid Services (CMS). Local Coverage Determination (LCD) No: L33831 - Surgical Dressings. (Contractor: CGS Administrators, LLC) Revision Effective Date: 01/01/2020 https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=33831&ver=32&Date=&DocID=L33831&bc=hAAAAAgAAAAA&. Accessed September, 2020.

2. Centers for Medicare and Medicaid Services (CMS). Local Coverage Determination (LCD) No: L37228– Wound Care. (Contractor: Wisconsin Physicians Service Insurance Corporation) Revision Effective Date: 02/09/2020. https://www.cms.gov/medicare-

https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=33831&ver=32&Date=&DocID=L33831&bc=hAAAAAgAAAAA&https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=33831&ver=32&Date=&DocID=L33831&bc=hAAAAAgAAAAA&https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=37228&ContrId=143&ver=12&ContrVer=1&SearchType=Advanced&CoverageSelection=Both&NCSelection=NCA%7cCAL%7cNCD%7cMEDCAC%7cTA%7cMCD&ArticleType=BC%7cSAD%7cRTC%7cReg&PolicyType=Both&s=All&KeyWord=Wound+Care&KeyWordLookUp=Doc&KeyWordSearchType=Exact&kq=true&bc=EAAAABAAgAAA&

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coverage-database/details/lcd-details.aspx?LCDId=37228&ContrId=143&ver=12&ContrVer=1&SearchType=Advanced&CoverageSelection=Both&NCSelection=NCA%7cCAL%7cNCD%7cMEDCAC%7cTA%7cMCD&ArticleType=BC%7cSAD%7cRTC%7cReg&PolicyType=Both&s=All&KeyWord=Wound+Care&KeyWordLookUp=Doc&KeyWordSearchType=Exact&kq=true&bc=EAAAABAAgAAA& Accessed September, 2020.

3. Centers for Medicare and Medicaid Services (CMS). Local Coverage Article: No. A53001 - Wound Care. Article Revision Effective Date: 11/09/2017. https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=53001&ver=32&Date=&DocID=A53001&bc=ggAAAAgAAAAA& . Accessed September, 2020.

4. Heenan A. World Wide Wounds: Dressings on the Drug Tariff,. Last modified 29 March 2001. ©1992- 2001, SMTL. http://www.worldwidewounds.com/1997/july/Heenan/Tariff.html#AbsAdh. Accessed September, 2020.

5. Rivera AE, Spencer JM. Clinical aspects of full-thickness wound healing. Clin Dermatol. 2007 Jan-Feb; 25(1): 39-48. http://www.ncbi.nlm.nih.gov/pubmed/17276200. Accessed September, 2020.

6. World Union of Wound Healing Societies (WUWHS). Principles of best practice: Wound exudate and the role of dressings. A consensus document. London: MEP, Ltd., 2019. Available at: http://www.woundsinternational.com/pdf/content_42.pdf Accessed September, 2020.

History

Date Comments 09/16/19 New policy, approved August 13, 2019, effective January 1, 2020. Surgical dressings

and wound care supplies may be considered medically necessary when all of the general and specific guidelines and criteria in this policy are met.

10/01/20 Annual Review, approved September 17, 2020. No changes to policy statement, references updated.

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 only applies to Individual Plans.

https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=37228&ContrId=143&ver=12&ContrVer=1&SearchType=Advanced&CoverageSelection=Both&NCSelection=NCA%7cCAL%7cNCD%7cMEDCAC%7cTA%7cMCD&ArticleType=BC%7cSAD%7cRTC%7cReg&PolicyType=Both&s=All&KeyWord=Wound+Care&KeyWordLookUp=Doc&KeyWordSearchType=Exact&kq=true&bc=EAAAABAAgAAA&https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=37228&ContrId=143&ver=12&ContrVer=1&SearchType=Advanced&CoverageSelection=Both&NCSelection=NCA%7cCAL%7cNCD%7cMEDCAC%7cTA%7cMCD&ArticleType=BC%7cSAD%7cRTC%7cReg&PolicyType=Both&s=All&KeyWord=Wound+Care&KeyWordLookUp=Doc&KeyWordSearchType=Exact&kq=true&bc=EAAAABAAgAAA&https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=37228&ContrId=143&ver=12&ContrVer=1&SearchType=Advanced&CoverageSelection=Both&NCSelection=NCA%7cCAL%7cNCD%7cMEDCAC%7cTA%7cMCD&ArticleType=BC%7cSAD%7cRTC%7cReg&PolicyType=Both&s=All&KeyWord=Wound+Care&KeyWordLookUp=Doc&KeyWordSearchType=Exact&kq=true&bc=EAAAABAAgAAA&https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=37228&ContrId=143&ver=12&ContrVer=1&SearchType=Advanced&CoverageSelection=Both&NCSelection=NCA%7cCAL%7cNCD%7cMEDCAC%7cTA%7cMCD&ArticleType=BC%7cSAD%7cRTC%7cReg&PolicyType=Both&s=All&KeyWord=Wound+Care&KeyWordLookUp=Doc&KeyWordSearchType=Exact&kq=true&bc=EAAAABAAgAAA&https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=37228&ContrId=143&ver=12&ContrVer=1&SearchType=Advanced&CoverageSelection=Both&NCSelection=NCA%7cCAL%7cNCD%7cMEDCAC%7cTA%7cMCD&ArticleType=BC%7cSAD%7cRTC%7cReg&PolicyType=Both&s=All&KeyWord=Wound+Care&KeyWordLookUp=Doc&KeyWordSearchType=Exact&kq=true&bc=EAAAABAAgAAA&https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=53001&ver=32&Date=&DocID=A53001&bc=ggAAAAgAAAAA&https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=53001&ver=32&Date=&DocID=A53001&bc=ggAAAAgAAAAA&http://www.worldwidewounds.com/1997/july/Heenan/Tariff.html#AbsAdhhttp://www.ncbi.nlm.nih.gov/pubmed/17276200http://www.woundsinternational.com/pdf/content_42.pdf

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If you need these services, contact the Civil Rights Coordinator.

If you believe that Premera has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator - Complaints and Appeals PO Box 91102, Seattle, WA 98111 Toll free 855-332-4535, Fax 425-918-5592, TTY 800-842-5357 Email AppealsDepartmentInquiries@Premera.com

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

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037338 (07-2016)

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

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ູຂໍ້

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ភាសាែខមរ ( ): ឹ

រងរបស់

Premera Blue Cross ។ របែហលជាមាន កាលបរ ិ ឆ ំខានេនៅកងេសចក

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នដ

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នានា េដើ ីនងរកសាទុ ៉ បរងស់ ុ ់ ក ឬរបាក់ ំ

អ

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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

ੰ

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ੋ ੰ ੂ ੱ ੁ ੋ ੋ ੈ ੰ

ੋ ੈ ੋ

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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

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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).