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HealthPartners

Coverage criteria policies

Dressing supplies

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

Prior authorization is not required for dressing supplies.

Coverage

Dressing supplies are generally covered subject to the indications listed below, and per your plan documents.

Indications that are covered

  1. When recommended as part of a treatment plan for:
    1. Burns: second and third degree
    2. Surgical wounds (open)
    3. Infected wounds
    4. Decubitus ulcer - Stage II, III, and IV
  2. Primary and secondary dressings used to treat an open wound caused or treated by a surgical procedure.
  3. Primary and secondary dressings required for treatment of debrided wounds, regardless of type of debridement.
  4. Sterile gloves if required. Non sterile gloves are only covered under the Hospice benefit.
  5. Sterile water is covered as part of dressing supplies, urinary supplies or tracheostomy care that is done in the home.
  6. Normal saline is covered when used for tracheostomy cares or for urinary supplies.
  7. Silicone gel sheeting is covered when required for treatment of burns or scars that may result in loss of function (i.e. involvement of joints), or when prescribed for pain control resulting from scars.

Indications that are not covered

Silicone gel sheeting is not covered for the following indications:

  1. When used solely to render a hypertrophic or keloid scar more aesthetically pleasing, with no functional improvement expected; or
  2. For open wounds.

Definitions

Therapeutic and protective coverings applied to wounds (i.e. surgical, debrided, decubitus, burns, etc.) Dressing supplies can include primary and secondary dressings.

Primary dressings are protective coverings applied directly to the wound or lesion. May include antiseptic and/or antimicrobial agents such as iodine-based, silver-based, or honey-based dressings.

Secondary dressings (such as adhesive tape, roll gauze, bandages and disposable compression material) secure the primary dressing and protect the wound.

Silicone gel sheeting is a soft, adhesive scar cover. It allows air in the wound to help with healing. Silicone gel sheeting has been proven effective when used to treat hypertrophic and keloid scars.

If available, codes for a procedure, device or diagnosis are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.

Codes

Description

A6025

Gel sheet for dermal or epidermal application, (e.g., silicone, hydrogel, other), each

CPT Copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy contact Member Services at 952-883-7979 or 1-800-233-9645.

References

  1. Armstrong DG, Meyr AJ. Basic principles of wound management. Up To Date last updated 11 May 2015.
  2. Gauglitz,G Hypertrophic scarring and keloids following burn injuries. In: UpToDate, Jeschke, M, (MD), UpToDate, Waltham, MA. (Accessed on February 28, 2018.)
  3. Tenenhaus M, Rennekampff, OH. Local treatment of burns: Topical antimicrobial agents and dressings. Up To Date last updated 26 June 2015.

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Policy activity

  • 07/01/1995 - Date of origin
  • 04/01/2017 - Effective date
Review date
  • 03/2018

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