L11449-LCD

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Automated World Health

Local Coverage Determination (LCD) for Surgical Dressings (L11449)

Contractor Information

Contractor Name CGS Administrators, LLC

LCD Information

Document Information

LCD ID Number L11449

LCD Title Surgical Dressings

Contractor's Determination Number SURG

AMA CPT/ADA CDT Copyright Statement

CPT only copyright 2002-2012 American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright © American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association.

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Oversight Region Region IV

DME Region LCD Covers Jurisdiction C

Original Determination Effective Date

For services performed on or after 10/01/1993

Original Determination Ending Date

Revision Effective Date

For services performed on or after 08/05/2011

Revision Ending Date

CMS National Coverage Policy

CMS Pub. 100-3, Medicare National Coverage Determinations Manual, Chapter 1, Section 270.5 Indications and Limitations of Coverage and/or Medical Necessity

For any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements. For the items addressed in this local coverage determination, the criteria for "reasonable and necessary", based on Social Security Act § 1862(a)(1)(A) provisions, are defined by the following indications and limitations of coverage and/or medical necessity.

If the coverage criteria described below are not met, the claim will be denied as not reasonable and necessary. For an item to be covered by Medicare, a written signed and dated order must be received by the supplier before

a claim is submitted. If the supplier bills for an item without first receiving the completed order, the item will be

denied as not reasonable and necessary.

Surgical dressings are covered for as long as they are medically necessary. Dressings over a percutaneous catheter or tube (e.g., intravascular, epidural, nephrostomy, etc.) are covered as long as the catheter or tube remains in place and after removal until the wound heals. (Refer to Coding Guidelines in the associated Policy Article)

Surgical dressings used in conjunction with investigational wound healing therapy (e.g., platelet derived wound healing formula) may be covered if 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.

When a wound cover with an adhesive border is being used, no other dressing is needed on top of it and additional tape is usually not required. Reasons for use of additional tape must be well documented. An adhesive border is usually more binding than that obtained with separate taping and is therefore indicated for use with wounds requiring less frequent dressing changes.

Use of more than one type of wound filler or more than one type of wound cover in a single wound is rarely medically necessary and the reasons must be well documented. An exception is an alginate or other fiber gelling dressing wound cover or a saline, water, or hydrogel impregnated gauze dressing which might need an additional wound cover.

It may not be appropriate to use some combinations of a hydrating dressing on the same wound at the same time as an absorptive dressing (e.g., hydrogel and alginate).

Because composite dressings, foam and hydrocolloid wound covers, and transparent film, when used as secondary dressings, are meant to be changed at frequencies less than daily, appropriate clinical judgment should be used to avoid their use with primary dressings which require more frequent dressing changes. When

claims are submitted for these dressings for changes greater than once every other day, the quantity in excess of that amount will be denied as not reasonable and necessary. While a highly exudative wound might require such a combination initially, with continued proper management the wound usually progresses to a point where the appropriate selection of these products results in the less frequent dressing changes which they are designed to allow. An example of an inappropriate combination is the use of a specialty absorptive dressing on top of non- impregnated gauze being used as a primary dressing.

Dressing size must be based on and appropriate to the size of the wound. For wound covers, the pad size is usually about 2 inches greater than the dimensions of the wound. For example, a 5 cm x 5 cm (2 in. x 2 in.) wound requires a 4 in. x 4 in. pad size.

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 (e.g., 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. No more than a one month's supply of dressings may be provided at one time, unless there is documentation to support the necessity of greater quantities in the home setting in an individual case. An even smaller quantity may be appropriate in the situations described above.

Surgical dressings must be tailored to the specific needs of an individual patient. When surgical dressings are provided in kits, only those components of the kit that meet the definition of a surgical dressing, that are ordered by the physician, and that are medically necessary are covered.

The following are some specific coverage guidelines for individual products when the products themselves are necessary in the individual patient. The medical necessity for more frequent change of dressings must be documented in the patient's medical record and submitted with the claim (see Documentation section).

ALGINATE OR OTHER FIBER GELLING DRESSING (A6196-A6199):

Alginate or other fiber gelling dressing covers are covered for moderately to highly exudative full thickness wounds (e.g., stage III or IV ulcers); and alginate or other fiber gelling dressing fillers for moderately to highly exudative full thickness wound cavities (e.g., stage III or IV ulcers). They are not medically necessary on dry wounds or wounds covered with eschar. Usual dressing change is up to once per day. One wound cover sheet of the approximate size of the wound or up to 2 units of wound filler (1 unit = 6 inches of alginate or other fiber gelling dressing rope) is usually used at each dressing change. It is usually inappropriate to use alginates or other fiber gelling dressings in combination with hydrogels.

COMPOSITE DRESSING (A6203-A6205):

Usual composite dressing change is up to 3 times per week, one wound cover per dressing change.

CONTACT LAYER (A6206-A6208):

Contact layer dressings are used to line the entire wound; they are not intended to be changed with each dressing change. Usual dressing change is up to once per week.

FOAM DRESSING (A6209-A6215):

Foam dressings are covered when used on full thickness wounds (e.g., stage III or IV ulcers) with moderate to heavy exudate. Usual dressing change for a foam wound cover used as a primary dressing is up to 3 times per week. When a foam wound cover is used as a secondary dressing for wounds with very heavy exudate, dressing change may be up to 3 times per week. Usual dressing change for foam wound fillers is up to once per day.

GAUZE, NON-IMPREGNATED (A6216-A6221, A6402-A6404, A6407):

Usual non-impregnated gauze dressing change is up to 3 times per day for a dressing without a border and once per day for a dressing with a border. It is usually not necessary to stack more than 2 gauze pads on top of each other in any one area.

GAUZE, IMPREGNATED, WITH OTHER THAN WATER, NORMAL SALINE, HYDROGEL, OR ZINC PASTE (A6222- A6224, A6266):

Usual dressing change for gauze dressings impregnated with other than water, normal saline, hydrogel or zinc paste is up to once per day.

GAUZE, IMPREGNATED, WATER OR NORMAL SALINE (A6228-A6230):

There is no medical necessity for these dressings compared to non-impregnated gauze which is moistened with bulk saline or sterile water. When these dressings are billed, they will be denied as not reasonable and necessary.

HYDROCOLLOID DRESSING (A6234-A6241):

Hydrocolloid dressings are covered for use on wounds with light to moderate exudate. Usual dressing change for hydrocolloid wound covers or hydrocolloid wound fillers is up to 3 times per week.

HYDROGEL DRESSING (A6231-A6233, A6242-A6248):

Hydrogel dressings are covered when used on full thickness wounds with minimal or no exudate (e.g., stage III or IV ulcers). Hydrogel dressings are not usually medically necessary for stage II ulcers. Documentation must substantiate the medical necessity for use of hydrogel dressings for stage II ulcers (e.g., location of ulcer is sacro

-coccygeal area). Usual dressing change for hydrogel wound covers without adhesive border or hydrogel wound fillers is up to once per day. Usual dressing change for hydrogel wound covers with adhesive border is up to 3 times per week.

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 code A6248 billed in excess of 3 units (fluid ounces) per wound in 30 days.

Use of more than one type of hydrogel dressing (filler, cover, or impregnated gauze) on the same wound at the same time is not medically necessary.

SPECIALTY ABSORPTIVE DRESSING (A6251-A6256):

Specialty absorptive dressings are covered when used for moderately or highly exudative wounds (e.g., stage III or IV ulcers). Usual specialty absorptive dressing change is up to once per day for a dressing without an adhesive border and up to every other day for a dressing with a border.

TRANSPARENT FILM (A6257-A6259):

Transparent film dressings are covered when used on open partial thickness wounds with minimal exudate or closed wounds. Usual dressing change is up to 3 times per week.

WOUND FILLER, NOT ELSEWHERE CLASSIFIED (A6261-A6262):

Usual dressing change is up to once per day.

WOUND POUCH (A6154):

Usual dressing change is up to 3 times per week.

TAPE (A4450, A4452):

Tape is covered when needed to hold on a wound cover, elastic roll gauze or non-elastic roll gauze. Additional tape is usually not required when a wound cover with an adhesive border is used. The medical necessity for tape in these situations must be documented. Tape change is determined by the frequency of change of the wound cover. Quantities of tape submitted must reasonably reflect the size of the wound cover being secured. Usual use for wound covers measuring 16 square inches or less is up to 2 units per dressing change; for wound covers measuring 16 to 48 square inches, up to 3 units per dressing change; for wound covers measuring greater than 48 square inches, up to 4 units per dressing change.

LIGHT COMPRESSION BANDAGE (A6448-A6450), MODERATE/HIGH COMPRESSION BANDAGE (A6451, A6452),SELF-ADHERENT BANDAGE (A6453-A6455), CONFORMING BANDAGE (A6442-A6447), PADDING BANDAGE (A6441):

Most compression bandages are reusable. Usual frequency of replacement would be no more than one per week unless they are part of a multi-layer compression bandage system.

Conforming bandage dressing change is determined by the frequency of change of the selected underlying dressing.

GRADIENT COMPRESSION WRAP (A6545):

Coverage of a non-elastic gradient compression wrap (A6545) is limited to one per 6 months per leg. Quantities exceeding this amount will be denied as not reasonable and necessary. Refer to Policy Article for statement concerning noncoverage if the ulcer has healed.

Coding Information

Bill Type Codes:

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

Revenue Codes:

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

CPT/HCPCS Codes

The appearance of a code in this section does not necessarily indicate coverage.

HCPCS MODIFIERS:

A1 – Dressing for one wound A2 – Dressing for two wounds

A3 – Dressing for three wounds

A4 – Dressing for four wounds A5 – Dressing for five wounds A6 – Dressing for six wounds

A7 – Dressing for seven wounds A8 – Dressing for eight wounds A9 – Dressing for nine wounds

AW – Item furnished in conjunction with a surgical dressing

EY – No physician or other licensed health care provider order for this item or service

GY - Item or service statutorily noncovered or does not meet the definition of any Medicare benefit LT - Left side

RT – Right side

HCPCS CODES:

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 A4465 NON-ELASTIC BINDER FOR EXTREMITY

A4490 SURGICAL STOCKINGS ABOVE KNEE LENGTH, EACH A4495 SURGICAL STOCKINGS THIGH LENGTH, EACH

A4500 SURGICAL STOCKINGS BELOW KNEE LENGTH, EACH

A4510 SURGICAL STOCKINGS FULL LENGTH, 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, STERILE, SIZE 16 SQ. IN. OR LESS, EACH

A6022 COLLAGEN DRESSING, STERILE, SIZE MORE THAN 16 SQ. IN. BUT LESS THAN OR EQUAL TO 48 SQ. IN., EACH

A6023 COLLAGEN DRESSING, STERILE, SIZE MORE THAN 48 SQ. IN., EACH A6024 COLLAGEN DRESSING WOUND FILLER, STERILE, PER 6 INCHES

A6025 GEL SHEET FOR DERMAL OR EPIDERMAL APPLICATION, (E.G., SILICONE, HYDROGEL, OTHER), EACH 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

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

GAUZE, IMPREGNATED WITH OTHER THAN WATER, NORMAL SALINE, OR HYDROGEL, STERILE, PAD SIZE A6223 MORE THAN 16 SQ. IN., BUT LESS THAN OR EQUAL TO 48 SQ. IN., WITHOUT ADHESIVE BORDER, EACH

DRESSING

A6224 GAUZE, IMPREGNATED WITH OTHER THAN WATER, NORMAL SALINE, OR HYDROGEL, STERILE, PAD SIZE MORE THAN 48 SQ. IN., WITHOUT ADHESIVE BORDER, EACH DRESSING

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

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 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

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

A6250 SKIN SEALANTS, PROTECTANTS, MOISTURIZERS, OINTMENTS, ANY TYPE, ANY SIZE

A6251 SPECIALTY ABSORPTIVE DRESSING, WOUND COVER, STERILE, 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, STERILE, 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 A6260 WOUND CLEANSERS, ANY TYPE, ANY SIZE

A6261 WOUND FILLER, GEL/PASTE, PER FLUID OUNCE, NOT OTHERWISE SPECIFIED

A6262 WOUND FILLER, DRY FORM, PER GRAM, NOT OTHERWISE SPECIFIED

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

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

MODERATE COMPRESSION BANDAGE, ELASTIC, KNITTED/WOVEN, LOAD RESISTANCE OF 1.25 TO 1.34 A6451 FOOT POUNDS AT 50% MAXIMUM STRETCH, WIDTH GREATER THAN OR EQUAL TO THREE INCHES AND

LESS THAN FIVE INCHES, PER YARD

HIGH COMPRESSION BANDAGE, ELASTIC, KNITTED/WOVEN, LOAD RESISTANCE GREATER THAN OR A6452 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 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 A6530 GRADIENT COMPRESSION STOCKING, BELOW KNEE, 18-30 MMHG, EACH

A6531 GRADIENT COMPRESSION STOCKING, BELOW KNEE, 30-40 MMHG, EACH A6532 GRADIENT COMPRESSION STOCKING, BELOW KNEE, 40-50 MMHG, EACH A6533 GRADIENT COMPRESSION STOCKING, THIGH LENGTH, 18-30 MMHG, EACH A6534 GRADIENT COMPRESSION STOCKING, THIGH LENGTH, 30-40 MMHG, EACH A6535 GRADIENT COMPRESSION STOCKING, THIGH LENGTH, 40-50 MMHG, EACH

A6536 GRADIENT COMPRESSION STOCKING, FULL LENGTH/CHAP STYLE, 18-30 MMHG, EACH

A6537 GRADIENT COMPRESSION STOCKING, FULL LENGTH/CHAP STYLE, 30-40 MMHG, EACH A6538 GRADIENT COMPRESSION STOCKING, FULL LENGTH/CHAP STYLE, 40-50 MMHG, EACH

A6539 GRADIENT COMPRESSION STOCKING, WAIST LENGTH, 18-30 MMHG, EACH A6540 GRADIENT COMPRESSION STOCKING, WAIST LENGTH, 30-40 MMHG, EACH A6541 GRADIENT COMPRESSION STOCKING, WAIST LENGTH, 40-50 MMHG, EACH A6544 GRADIENT COMPRESSION STOCKING, GARTER BELT

A6545 GRADIENT COMPRESSION WRAP, NON-ELASTIC, BELOW KNEE, 30-50 MM HG, EACH

A6549 GRADIENT COMPRESSION STOCKING/SLEEVE, NOT OTHERWISE SPECIFIED A9270 NON-COVERED ITEM OR SERVICE

ICD-9 Codes that Support Medical Necessity AsteriskNoteText

Diagnoses that Support Medical Necessity

ICD-9 Codes that DO NOT Support Medical Necessity

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation

Diagnoses that DO NOT Support Medical Necessity

General Information

Documentations Requirements

Section 1833(e) of the Social Security Act precludes payment to any provider of services unless "there has been furnished such information as may be necessary in order to determine the amounts due such provider". It is expected that the patient's medical records will reflect the need for the care provided. The patient's medical records include the physician's office records, hospital records, nursing home records, home health agency records, records from other healthcare professionals and test reports. This documentation must be available upon request.

An order for each item billed must be signed and dated by the treating physician, kept on file by the supplier, and made available upon request. Items billed before a signed and dated order has been received by the supplier must be submitted with an EY modifier added to each affected HCPCS code.

The order must specify (a) the type of dressing (e.g., hydrocolloid wound cover, hydrogel wound filler, etc.), (b) the size of the dressing (if appropriate), (c) the number/amount to be used at one time (if more than one), (d) the frequency of dressing change, and (e) the expected duration of need.

A new order is needed if a new dressing is added or if the quantity of an existing dressing to be used is increased. A new order is not routinely needed if the quantity of dressings used is decreased. However a new order is required at least every 3 months for each dressing being used even if the quantity used has remained the same

or decreased.

Information defining the number of surgical/debrided wounds being treated with a dressing, the reason for dressing use (e.g., surgical wound, debrided wound, etc.), and whether the dressing is being used as a primary or secondary dressing or for some noncovered use (e.g., wound cleansing) must be obtained from the physician, nursing home, or home care nurse. The source of that information and date obtained must be documented in the supplier's records.

Current clinical information which supports the reasonableness and necessity of the type and quantity of surgical dressings provided must be present in the patient's medical records. Evaluation of a patient's wound(s) must be performed at least on a monthly basis unless there is documentation in the medical record which justifies why an evaluation could not be done within this timeframe and what other monitoring methods were used to evaluate the patient's need for dressings. Evaluation is expected on a more frequent basis (e.g., weekly) in patients in a nursing facility or in patients with heavily draining or infected wounds. The evaluation may be performed by a nurse, physician or other health care professional. This evaluation must include the type of each wound (e.g., surgical wound, pressure ulcer, burn, etc), its location, its size (length x width in cm.) and depth, the amount of drainage, and any other relevant information. This information must be available upon request.

When surgical dressings are billed, the appropriate modifier (A1 “ A9, AW, EY, or GY) must be added to the code when applicable. If A9 is used, information must be submitted with the claim indicating the number of wounds. If GY is used, a brief description of the reason for non-coverage (e.g., "A6216GY - used for wound cleansing") must be entered in the narrative field of the electronic claim.

When codes A4649, A6261 or A6262 are billed, the claim must include a narrative description of the item (including size of the product provided), the manufacturer, the brand name or number, and information justifying the medical necessity for the item. This information must be entered in the narrative field of the electronic claim.

Refer to the Supplier Manual for more information on documentation requirements. Appendices The staging of pressure ulcers used in this policy is as follows:

Suspected Deep Tissue Injury: Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.

Stage I - Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area.

Stage II - Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.

Stage III - Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.

Stage IV - Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling.

Unstageable: Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed.

Utilization Guidelines Refer to Indications and Limitations of Coverage and/or Medical Necessity.

Sources of Information and Basis for Decision

National Pressure Ulcer Advisory Panel (NPUAP) Revised Staging Definitions for Pressure Ulcers accessed at

www.npuap.org on August 28, 2008 Advisory Committee Meeting Notes

Start Date of Comment Period 04/30/1993

End Date of Comment Period 06/14/1993

Start Date of Notice Period 08/01/1993

Revision History Number 010

Revision History Explanation Revision Effective Date: 02/04/2011 INDICATIONS AND LIMITATIONS OF COVERAGE:

Deleted: Least costly alternative for HCPCS codes A6228-A6230 HCPCS CODES: (effective 1/01/2011)

Revised: A6011, A6248, A6260-A6262

11/21/2010 - For the following CPT/HCPCS codes either the short description and/or the long description was changed. Depending on which description is used in this LCD, there may not be any change in how the code displays in the document:

A6011 descriptor was changed in Group 1 A6248 descriptor was changed in Group 1 A6260 descriptor was changed in Group 1 A6261 descriptor was changed in Group 1 A6262 descriptor was changed in Group 1 A6441 descriptor was changed in Group 1 A6442 descriptor was changed in Group 1

A6443 descriptor was changed in Group 1 A6444 descriptor was changed in Group 1 A6445 descriptor was changed in Group 1 A6446 descriptor was changed in Group 1 A6447 descriptor was changed in Group 1 A6448 descriptor was changed in Group 1 A6449 descriptor was changed in Group 1 A6450 descriptor was changed in Group 1 A6451 descriptor was changed in Group 1 A6452 descriptor was changed in Group 1 A6453 descriptor was changed in Group 1 A6454 descriptor was changed in Group 1 A6455 descriptor was changed in Group 1 A6456 descriptor was changed in Group 1

Revision Effective Date: 01/01/2010 INDICATIONS AND LIMITATIONS OF COVERAGE:

Removed: A6200-A6202 from composite dressing reference Clarified: Usual dressing changes for gauze with zinc paste HCPCS CODES:

Deleted: A6200, A6201, A6202, A6542, A6543

Revision Effective Date: 11/15/2009

The description for CPT/HCPCS code A6022 was changed in group 1 The description for CPT/HCPCS code A6549 was changed in group 1 CPT/HCPCS code A6200 was deleted from group 1

CPT/HCPCS code A6201 was deleted from group 1

CPT/HCPCS code A6202 was deleted from group 1 CPT/HCPCS code A6542 was deleted from group 1 CPT/HCPCS code A6543 was deleted from group 1

Revision Effective Date: 01/01/2009 INDICATIONS AND LIMITATIONS OF COVERAGE:

Added: Frequency of replacement for compression wrap (A6545) HCPCS CODES:

Added: A4490-A4510, A6545

Revised: A6010-A6024, A6196-A6199, A6203-A6215, A6219-A6248, A6251-A6266, A6407 APPENDICES:

Revised: Definitions of pressure ulcer stages

SOURCES OF INFORMATION AND BASIS FOR DECISION:

Added: Reference to NPUAP guidelines for pressure ulcer staging

11/09/2008 - The description for CPT/HCPCS code A6010 was changed in group 1 The description for CPT/HCPCS code A6011 was changed in group 1

The description for CPT/HCPCS code A6021 was changed in group 1 The description for CPT/HCPCS code A6022 was changed in group 1 The description for CPT/HCPCS code A6023 was changed in group 1 The description for CPT/HCPCS code A6024 was changed in group 1 The description for CPT/HCPCS code A6196 was changed in group 1 The description for CPT/HCPCS code A6197 was changed in group 1 The description for CPT/HCPCS code A6198 was changed in group 1 The description for CPT/HCPCS code A6199 was changed in group 1 The description for CPT/HCPCS code A6203 was changed in group 1 The description for CPT/HCPCS code A6204 was changed in group 1 The description for CPT/HCPCS code A6205 was changed in group 1 The description for CPT/HCPCS code A6206 was changed in group 1 The description for CPT/HCPCS code A6207 was changed in group 1 The description for CPT/HCPCS code A6208 was changed in group 1 The description for CPT/HCPCS code A6209 was changed in group 1 The description for CPT/HCPCS code A6210 was changed in group 1 The description for CPT/HCPCS code A6211 was changed in group 1 The description for CPT/HCPCS code A6212 was changed in group 1 The description for CPT/HCPCS code A6213 was changed in group 1 The description for CPT/HCPCS code A6214 was changed in group 1 The description for CPT/HCPCS code A6215 was changed in group 1 The description for CPT/HCPCS code A6219 was changed in group 1 The description for CPT/HCPCS code A6220 was changed in group 1

The description for CPT/HCPCS code A6221 was changed in group 1 The description for CPT/HCPCS code A6222 was changed in group 1 The description for CPT/HCPCS code A6223 was changed in group 1 The description for CPT/HCPCS code A6224 was changed in group 1 The description for CPT/HCPCS code A6228 was changed in group 1 The description for CPT/HCPCS code A6229 was changed in group 1 The description for CPT/HCPCS code A6230 was changed in group 1 The description for CPT/HCPCS code A6231 was changed in group 1 The description for CPT/HCPCS code A6232 was changed in group 1 The description for CPT/HCPCS code A6233 was changed in group 1 The description for CPT/HCPCS code A6234 was changed in group 1 The description for CPT/HCPCS code A6235 was changed in group 1 The description for CPT/HCPCS code A6236 was changed in group 1 The description for CPT/HCPCS code A6237 was changed in group 1 The description for CPT/HCPCS code A6238 was changed in group 1 The description for CPT/HCPCS code A6239 was changed in group 1 The description for CPT/HCPCS code A6240 was changed in group 1 The description for CPT/HCPCS code A6241 was changed in group 1 The description for CPT/HCPCS code A6242 was changed in group 1 The description for CPT/HCPCS code A6243 was changed in group 1 The description for CPT/HCPCS code A6244 was changed in group 1 The description for CPT/HCPCS code A6245 was changed in group 1 The description for CPT/HCPCS code A6246 was changed in group 1 The description for CPT/HCPCS code A6247 was changed in group 1 The description for CPT/HCPCS code A6248 was changed in group 1 The description for CPT/HCPCS code A6251 was changed in group 1 The description for CPT/HCPCS code A6252 was changed in group 1 The description for CPT/HCPCS code A6253 was changed in group 1 The description for CPT/HCPCS code A6254 was changed in group 1 The description for CPT/HCPCS code A6255 was changed in group 1 The description for CPT/HCPCS code A6256 was changed in group 1 The description for CPT/HCPCS code A6257 was changed in group 1 The description for CPT/HCPCS code A6258 was changed in group 1 The description for CPT/HCPCS code A6259 was changed in group 1 The description for CPT/HCPCS code A6260 was changed in group 1 The description for CPT/HCPCS code A6261 was changed in group 1 The description for CPT/HCPCS code A6262 was changed in group 1 The description for CPT/HCPCS code A6266 was changed in group 1 The description for CPT/HCPCS code A6407 was changed in group 1

03/01/2008 - In accordance with Section 911 of the Medicare Modernization Act, this policy was transitioned to DME MAC CIGNA Government Services (18003) LCD L11517 from DME PSC TrustSolutions (77012) LCD L11517.

Revision Effective Date: 01/01/2008 HCPCS CODES:

Added: A6413

06/01/2007 - In accordance with Section 911 of the Medicare Modernization Act of 2003, Virginia and West Virginia were transitioned from DME PSC TriCenturion (77011) to DME PSC TrustSolutions (77012).

Revision Effective Date: 01/01/2007 INDICATIONS AND LIMITATIONS OF COVERAGE:

Removed: References to DMERC HCPCS CODES:

Added: A4461, A4463

Deleted: A4462

DOCUMENTATION REQUIREMENTS:

Revised: Section on current clinical information. Revised: Instructions for GY modifier

Revised: Instructions for codes A4649, A6261 and A6262.

03/01/2006 - In accordance with Section 911 of the Medicare Modernization Act of 2003, this policy was transitioned to DME PSC TrustSolutions (77012) from DMERC Palmetto GBA (00885).

Revision Effective Date: 01/01/2006 HCPCS CODES:

Added: A6457, A6513, A6530-A6549 Deleted: K0620, L8100-L8239

01/01/2005 - LMRP converted to LCD and Policy Article Revision Effective Date: 04/01/2004

HCPCS CODES:

Added: A6025, A6407, A6441-A6456

Discontinued: A6421- A6440, K0621-K0626 INDICATIONS AND LIMITATIONS OF COVERAGE:

Adds statement that silicone gel sheets used for the treatment of keloids or other scars are noncovered. CODING GUIDELINES:

Provides guidelines for billing A6025, gel sheet. Revises references to discontinued codes.

Revision Effective Date: 10/01/2003 HCPCS CODES:

Added: A4465, K0622-K0626, L8100-L8239, LT, RT

INDICATIONS AND LIMITATIONS OF COVERAGE:

Added references to new K codes.

Added new section on Gradient Compression Stockings which addresses coverage of L8100-L8239 and A4465. CODING GUIDELINES:

Added references to new K codes.

Added guidelines for codes L8110 and L8120, including use of AW and LT/RT modifiers.

Revision Effective Date: 07/01/2003 HCPCS CODES AND MODIFIERS: Added K0620, K0621

INDICATIONS AND LIMITATIONS OF COVERAGE:

Added references to new codes. CODING GUIDELINES:

Added references to new codes.

Revision Effective Date: 04/01/2003 HCPCS CODES AND MODIFIERS:

Added: A4450, A4452, A6011, A6410-A6412, A6421-A6422, A6424, A6426, A6428, A6430, A6432, A6434, A6436, A6438, A6440, A6501-A6512, A1-A9, AW, EY

Discontinued: A4460, A6263-A6264, A6405-A6406, K0572-K0573 X1-X9

Revised: A4462, A6266

INDICATIONS AND LIMITATIONS OF COVERAGE:

Adds standard language concerning coverage of items without an order.

Revises/adds statement concerning coverage of compression bandages, conforming bandages, self-adherent bandages, and padding bandages.

CODING GUIDELINES:

Moves most of Definitions section to Coding Guidelines. Adds description of the term elastic.

Adds description of conforming bandages and compression bandages.

Adds requirement to use AW modifier when tape codes are used with surgical dressings. Revises description of multi-layer compression bandage systems.

DOCUMENTATION REQUIREMENTS:

Adds standard language concerning use of EY modifier for items without an order. OTHER COMMENTS:

Moves definitions of pressure ulcer staging to this section.

The revision dates listed below are the dates the revisions were published and not necessarily the effective dates for the revisions.

04/01/2002 - Included HCPCS code changes that have been made since the policy was last published – A6010- A6024, A6196-A6202, A6222-A6224, A6231-A6233. Current code for tape, A6265, made invalid for DMERC and two new codes for tape, K0572 and K0573, established. Substituted GY modifier for ZY modifier. Added coverage and coding guidelines for compression bandage systems used for the treatment of venous stasis ulcers. Added statement about

coverage of compression dressings. Revised coverage statements concerning secondary dressings to allow for multi-layer compression bandage systems. Revised statements regarding kits to clarify coverage of medically necessary components of kits. Impregnated roll gauze dressings designed for the treatment of venous stasis ulcers (e.g., Unna Boot) are coded using A6266. Removed

specific mention of Nurse Practitioners, Physician Assistants, and other non-physician practitioners in statements about documentation requirements. This is to be consistent with wording in other policies. The general statements about the acceptance of orders from non-

physician practitioners which are found in the supplier manual continue to apply to this policy.

03/01/1998 – Added HCPCS code A4462.

12/01/1996 – Various HCPCS K codes crosswalked to A codes.

10/01/1995 – Revised language in Coverage and Payment Rules to: “Surgical dressings used in conjunction with investigational wound healing therapy (e.g., platelet derived wound healing formula) may be covered if 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.”

07/01/1995 – HCPCS codes and modifiers added. Revisions made to the entire policy. 12/01/1993 – Corrected HAO to HA0 in Documentation section.

08/05/2011 - The Jurisdiction C contractor adopted a new business name. This LCD revision only includes the change from CIGNA Government Services to CGS Administrators, LLC. No coverage information was included in this revision and no provider action is needed regarding this revision.

11/21/2011 - For the following CPT/HCPCS codes either the short description and/or the long description was changed. Depending on which description is used in this LCD, there may not be any change in how the code displays in the document:

A6441 descriptor was changed in Group 1 A6442 descriptor was changed in Group 1 A6443 descriptor was changed in Group 1 A6444 descriptor was changed in Group 1 A6445 descriptor was changed in Group 1 A6446 descriptor was changed in Group 1 A6447 descriptor was changed in Group 1 A6448 descriptor was changed in Group 1 A6449 descriptor was changed in Group 1 A6450 descriptor was changed in Group 1 A6451 descriptor was changed in Group 1 A6452 descriptor was changed in Group 1 A6453 descriptor was changed in Group 1 A6454 descriptor was changed in Group 1 A6455 descriptor was changed in Group 1 A6456 descriptor was changed in Group 1

11/25/2012 - For the following CPT/HCPCS codes either the short description and/or the long description was changed. Depending on which description is used in this LCD, there may not be any change in how the code displays in the document:

A6021 descriptor was changed in Group 1 A6022 descriptor was changed in Group 1 A6023 descriptor was changed in Group 1

Reason for Change