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Clinical Policy Bulletin:
Burn Garments
Number: 0062


Policy

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.

See also CPB 0172 - Hyperbaric Oxygen Therapy (HBOT)CPB 0250 - Occupational Therapy ServicesCPB 0389 - Hypertrophic Scars and Keloids, and CPB 0482 - Compression Garments for the Legs.



Background

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., chest, face, hands, joints, and upper legs) are most susceptible to scarring and contractures.  Follow-up visits are initially scheduled 7 to 14 days after discharge, and then every 1 to 2 weeks for the next 2 months, finally every month for about 3 months, and then every 3 months until their hypertrophic scar matures and they no longer need compression garments (usually a period of 12 months).

Standard care for the prevention of abnormal scarring after burn injury includes pressure garment therapy (PGT); however, it is associated with potential patient morbidity and high costs.  In a meta-analysis, Anzarut et al (2009) examined the effectiveness of PGT for the prevention of abnormal scarring following burn injury.  This study had 3 aims: (i) to conduct a systematic review to identify the available evidence for the use of pressure garment therapy (PGT); (ii) to assess the quality of the available evidence; and (iii) to conduct a meta-analysis to quantify the effectiveness of PGT for the prevention of abnormal scarring following burn.  Randomized control trials were identified from CINHAL, EMBASE, MEDLINE, CENTRAL, the "grey literature" and hand searching of the Proceedings of the American Burn Association. Primary authors and pressure garment manufacturers were contacted to identify eligible trials.  Bibliographies from included studies and reviews were searched.  Study results were pooled to yield weighted mean differences (WMD) or standardized mean difference (SMD) and reported using 95 % confidence intervals (CIs).  The review incorporated 6 unique trials involving 316 patients.  Original data from 1 unpublished trial were included.  Overall, studies were considered to be of high methodological quality.  The meta-analysis was unable to demonstrate a difference between global assessments of PGT-treated scars and control scars (WMD: -0.46; 95 % CI: -1.07 to 0.16).  The meta-analysis for scar height showed a small, but statistically significant, decrease in height for the PGT-treated group (SMD: -0.31; 95 % CI: -0.63 to 0.00).  Results of meta-analyses of secondary outcome measures of scar vascularity, pliability and color failed to show a difference between groups.  The authors concluded that PGT does not appear to alter global scar scores.  It does appear to improve scar height, although this difference is small and of questionable clinical importance.  The beneficial effects of PGT remain unproven, while the potential morbidity and cost are not insignificant.  Given current evidence, additional research is needed to ascertain the effectiveness, risks and costs of PGT.

There is a lack of evidence that pressure garments and silicone sheeting result in improved outcomes compared to pressure garments alone.  In a pilot study, Harte et al (2009) examined if pressure and silicone therapy used simultaneously are more effective in treating multiple characteristics of hypertrophic scars than pressure alone.  A total of 22 subjects with hypertrophic burn scars were randomized to receive Jobskin pressure garments and Mepiform silicone sheeting or Jobskin pressure garments alone.  The Vancouver Scar Scale (VSS) was used to measure multiple scar characteristics at baseline, week 12, and week 24.  No statistically significant difference was found in the rate of change of the VSS scores between the pressure therapy (PT) group and the PT plus silicone group at week 12 or week 24; however, the mean scores of both groups decreased over 24 weeks.  There were no statistically significant changes in the VSS subscores (pigmentation, pliability, scar height, and vascularity) from baseline to week 12 or week 24.  A statistically significant relationship was observed between the VSS score and total burn surface area (less than 30 %) in the PT group at baseline (p < 0.05), over 12 weeks (p < 0.05), and over 24 weeks (p < 0.05).  The authors noted that given the limitations of this study, especially the small sample size, further research is needed before any firm conclusions can be drawn on this therapy approach.  However, this pilot study has discussed the recurring issues in the research regarding these controversial treatments and has yielded potential for further investigation in a fully powered randomized controlled trial.

 
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
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 (pantry), custom fabricated
A6512 Compression burn garment, not otherwise classified
A6513 Compression burn mask, face, and/or neck, plastic or equal, custom fabricated
Other HCPCS codes related to the CPB:
G0151 Services performed by a qualified physical therapist in the home health or hospice setting, each 15 minutes
G0152 Services performed by a qualified occupational therapist in the home health or hospice 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:
  1. 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.
  2. 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.
  3. Wienert V. Compression treatment after burns. Wien Med Wochenschr. 1999;149(21-22):581-582.
  4. 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.
  5. Staley MJ, Richard RL. Use of pressure to treat hypertrophic burn scars. Adv Wound Care. 1997;10(3):44-46.
  6. King SD, Blomberg PA, Pegg SP. Preventing morphological disturbances in burn-scarred children wearing compressive face garments. Burns. 1994;20(3):256-259.
  7. Puzey G. The use of pressure garments on hypertrophic scars. J Tissue Viability. 2002;12(1):11-15.
  8. Rappoport K, Müller R, Flores-Mir C. Dental and skeletal changes during pressure garment use in facial burns: A systematic review. Burns. 2008;34(1):18-23.
  9. Anzarut A, Olson J, Singh P, et al. The effectiveness of pressure garment therapy for the prevention of abnormal scarring after burn injury: A meta-analysis. J Plast Reconstr Aesthet Surg. 2009;62(1):77-84.
  10. Harte D, Gordon J, Shaw M, et al. The use of pressure and silicone in hypertrophic scar management in burns patients: A pilot randomized controlled trial. J Burn Care Res. 2009;30(4):632-642.
  11. Engrav LH, Heimbach DM, Rivara FP, et al. 12-Year within-wound study of the effectiveness of custom pressure garment therapy. Burns. 2010;36(7):975-983.
  12. Endorf FW, Ahrenholz D. Burn management. Curr Opin Crit Care. 2011;17(6):601-605.


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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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