Aetna considers burn garments and associated physical and occupational therapy medically necessary when all of the following criteria are met:
The burn is of documented significance to place the member at risk of a post-burn contracture; and
The burn garment and physical and occupational therapies are being used with the intent of preventing the need for skin grafting or contractures as a result of hypertrophic scarring; and
The burn garment is authorized by the primary care physician and/or the treating specialist.
Note: Burn garments, such as inflatable compression garments used with a pump to apply controlled pressure to stimulate circulation, are considered durable medical equipment (DME). Please check benefit plan descriptions for details on DME coverage.
Burn patients frequently require prolonged follow-up care after injury. Follow-up is typically done as an outpatient to a burn clinic where the patient is seen by a burn therapist. Positioning, splinting, exercise, and pressure garments help preserve function and appearance as burn wounds heal. Body surfaces with high skin tension and movement (e.g., face, hands, joints, upper legs, and chest) are most susceptible to scarring and contractures. Follow-up visits are initially scheduled seven to fourteen days after discharge, and then every one to two weeks for the next two months, finally every month for about three months, and then every three months until their hypertrophic scar matures and they no longer need compression garments (usually a period of twelve months).
CPT Codes / HCPCS Codes / ICD-9 Codes
Other CPT codes related to the CPB:
97001 - 97006
97010 - 97028
97032 - 97039
97110 - 97546
HCPCS codes covered if selection criteria are met:
A6501
Compression burn garment, bodysuit (head to foot), custom fabricated
Services of physical therapist in home health setting, each 15 minutes
G0152
Services of occupational therapist in home health setting, each 15 minutes
S8990
Physical or manipulative therapy performed for maintenance rather than restoration
S9129
Occupational therapy, in the home, per diem
S9131
Physical therapy; in the home, per diem
ICD-9 codes covered if selection criteria are met:
940.0 - 946.5
Burns
Other ICD-9 codes related to the CPB:
701.4
Keloid scar
709.2
Scar conditions and fibrosis of skin
718.40 - 718.49
Contracture of joint
906.5
Late effect of burn of eye, face, head, and neck
906.6
Late effect of burn of wrist and hand
906.7
Late effect of burn of other extremities
906.8
Late effect of burns of other specific sites
906.9
Late effect of burn of unspecified site
V53.7
Fitting and adjustment of orthopedic device
V53.99
Fitting and adjustment of other device
V54.89
Other orthopedic aftercare
V57.89
Care involving other rehabilitative procedure
V58.77
Aftercare following surgery of the skin and subcutaneous tissue
V58.89
Other specified aftercare
The above policy is based on the following references:
Byl N, Cameron M, Kloth LC, Rosenberg Zellerback L. Treatment and prevention: Goals and objectives. In: Saunders Manual of Physical Therapy Practice. R Sgarlat Myers, ed., Philadelphia, PA: WB Saunders Company; 1995:657-660.
Rivers EA, Fisher ST. Rehabilitation for burn patients. In: Krusen's Handbook of Physical Medicine and Rehabilitation. 4th ed. FJ Kottke, JF Lehmann. eds. Philadelphia, PA: WB Saunders Company; 1990:1088-1090.
Wienert V. Compression treatment after burns. Wien Med Wochenschr. 1999;149(21-22):581-582.
Rose MP, Deitch EA. The clinical use of a tubular compression bandage, Tubigrip, for burn-scar therapy: A critical analysis. Burns Incl Therm Inj. 1985;12(1):58-64.
Staley MJ, Richard RL. Use of pressure to treat hypertrophic burn scars. Adv Wound Care. 1997;10(3):44-46.
King SD, Blomberg PA, Pegg SP. Preventing morphological disturbances in burn-scarred children wearing compressive face garments. Burns. 1994;20(3):256-259.
Puzey G. The use of pressure garments on hypertrophic scars. J Tissue Viability. 2002;12(1):11-15.
Anzarut A, Singh P, Tredget EE, et al. Pressure garment therapy after burn injury [Protocol for Cochrane Review]. Cochrane Database Syst Rev. 2004;(2):CD004989.
Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.
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