Notes: Aetna’s standard traditional plans (Managed Choice POS, PPO, and indemnity) cover medically necessary surgical dressings only when prescribed by a physician and supplied by a home care agency in conjunction with covered home health care services or when dispensed and used by a participating health care provider in conjunction with treatment of the member.  Under Aetna traditional plans, supplies are not covered when they do not require a prescription and can be purchased by the member over-the counter or when they are given to the member as take-home supplies. Please check benefit plan descriptions.

Aetna’s standard HMO plans cover surgical dressings when they are medically necessary for wound debridement or for the treatment of a wound caused by, or treated by, a surgical procedure.  Please check benefit plan descriptions.

Covered surgical dressings include both medically necessary primary dressings (i.e., therapeutic or protective coverings applied directly to wounds or lesions either on the skin or caused by an opening to the skin) and medically necessary secondary dressings (i.e., materials that serve a therapeutic or protective function and that are needed to secure a primary dressing).  Items such as adhesive tape, roll gauze, or elastic bandages are examples of secondary dressings. Elastic stockings, support hose, foot coverings, leotards, knee supports, surgical leggings, gauntlets, and pressure garments for the arms and hands are examples of items that are not ordinarily covered as surgical dressings.

Debridement:

Note: Debridement of a wound may be any type of debridement, including surgical (e.g., sharp instrument or laser), mechanical (e.g., irrigation or wet-to-dry dressings), chemical (e.g., topical application of enzymes), or autolytic (e.g., application of occlusive dressings to an open wound). Medically necessary dressings used for mechanical debridement, to cover chemical debriding agents, or to cover wounds to allow for autolytic debridement are covered under both HMO and traditional plans under the surgical dressings benefit, although the chemical debriding agents themselves, if self-administered, are covered under the pharmacy benefit.

Dressings over a percutaneous catheter or tube:

Note: Under all plans, medically necessary dressings over a percutaneous catheter or tube (e.g., intravascular, epidural, nephrotomy, etc.) are covered as long as the catheter or tube remains in place and after removal until the wound heals.

Non-covered dressings:

Examples of situations in which dressings are of no proven benefit include the following:

1. Drainage from a cutaneous fistula which has not been caused by or treated by a surgical procedure;
2. A Stage I pressure ulcer;
3. A first degree burn;
4. Wounds caused by trauma which do not require surgical closure or debridement - e.g., skin tear or abrasion;
5. A venipuncture or arterial puncture site (e.g., blood sample) other than the site of an indwelling catheter or needle.

Wound covers:

Wound covers are flat dressing pads. A wound cover with adhesive border is one that has an integrated cover and distinct adhesive border designed to adhere tightly to the skin. When a wound cover with an adhesive border is being used, no other dressing would be used on top of it and additional tape is usually not considered medically necessary.  Reasons for use of additional tape should be documented.  An adhesive border is usually more binding than that obtained with separate taping and is therefore considered medically necessary for use with wounds requiring less frequent dressing changes.

Note on wound care items not covered under the surgical dressings benefit:

Note: The following are examples of wound care items which would not be covered under the surgical dressings benefit:

• Skin sealants or barriers,
• Wound cleansers or irrigating solutions,
• Solutions used to moisten gauze (e.g., saline),
• Topical antiseptics,
• Topical antibiotics,
• Enzymatic debriding agents,
• Gauze or other dressings used to cleanse or debride a wound but not left on the wound.

If medically necessary and available by prescription, some of these items may be covered under the pharmacy benefit if ordered by a physician.

Quantity of surgical dressings:

The medically necessary 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 person is actually using and to adjust their provision of dressings accordingly.  No more than a one-month's supply of dressings is considered medically necessary at one time, unless there is documentation to support the medical 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 dressing kits:

A surgical dressing kit is defined as non-individualized, standardized packaging containing repetitive quantities of dressings not related to the individual medical needs of a member, or whose contents have not each been prescribed for the care of the specific wounds of that member, or that contain materials in addition to surgical dressings.  Surgical dressings must be tailored to the specific needs of an individual member.  This cannot be accomplished when dressings are provided as kits or trays containing fixed quantities and/or multiple types of dressings.  When surgical dressing kits are used for the provision of surgical dressings, all components of the kit will be considered not medically necessary.

Wound fillers:

Wound fillers are dressing materials that are placed into open wounds to eliminate dead space, absorb exudate, or maintain a moist wound surface.

Wound fillers come in hydrated forms (e.g., pastes, gels), dry forms (e.g., powder, granules, beads), or other forms such as rope, spiral, pillows, etc.

Products containing multiple materials are categorized according to the clinically predominant component (e.g., alginate, foam, gauze, hydrocolloid, hydrogel).  Other multi-component wound dressings not containing these specified components may be classified as composite or specialty absorptive dressings if the definition of these categories has been met.  Gauze or gauze-like products are typically manufactured as a single piece of material folded into a several ply gauze pad.  Use of more than one type of wound filler or more than one type of wound cover in a single wound is rarely considered medically necessary.  It may not be considered medically necessary 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 would require more frequent dressing changes.  For these dressings, changes greater than once every other day are not considered medically necessary.  While a highly exudative wound might require such a combination initially, with continued proper management the wound should progress to a point where the appropriate selection of these products should result in the less frequent dressing changes which they are designed to allow.  An example of a combination that would be considered not medically necessary is the use of a specialty absorptive dressing on top of non-impregnated gauze being used as a primary dressing.

Dressing size should be based on and appropriate to the size of the wound.  For wound covers, the medically necessary pad size should usually be about 2 inches greater than the dimensions of the wound.  For example, a 5 cm X 5 cm (2 in. X 2 in.) wound would require a 4 in. X 4 in. pad size.

The following are some specific medical necessity guidelines for individual products when the products themselves are considered medically necessary in the individual member.  The medical necessity for more frequent change of dressing should be documented in the member's medical record.

Alginate dressing:

Alginate dressing covers are considered medically necessary for moderately to highly exudative full thickness wounds (e.g., stage III or IV ulcers); and alginate fillers for moderately to highly exudative full thickness wound cavities (e.g., stage III or IV ulcers). They are of no proven benefit on dry wounds or wounds covered with eschar. Up to one dressing change per day is considered medically necessary, unless the medical necessity of more frequent changes is documented. 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 rope) would be considered medically necessary for each dressing change, unless the medical necessity for more wound cover or filler is documented. It is usually not considered medically necessary to use alginates in combination with hydrogels.

Composite dressing:

Composite dressings are products combining physically distinct components into a single dressing that provides multiple functions.  These functions must include, but are not limited to: (a) a bacterial barrier, (b) an absorptive layer other than an alginate, foam, hydrocolloid, or hydrogel, (c) either a semi-adherent or non-adherent property over the wound site, and (d) an adhesive border.  Up to 3 composite dressing changes per week are considered medically necessary, one wound cover per dressing change, unless it is documented that more frequent changes are medically necessary.

Contact layer:

Contact layers are thin non-adherent sheets placed directly on an open wound bed to protect the wound tissue from direct contact with other agents or dressings applied to the wound.  They are porous to allow wound fluid to pass through for absorption by an overlying dressing.  Contact layer dressings are used to line the entire wound; they are not intended to be changed with each dressing change.  Up to one contact layer dressing change per week is considered medically necessary, unless it is documented that more frequent changes are medically necessary.

Foam dressing:

Foam dressings are considered medically necessary 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 changes may be medically necessary up to 3 times per week.  Up to one dressing change for foam wound fillers per day is considered medically necessary, unless it is documented that more frequent changes are medically necessary.

Gauze, non-impregnated:

For a dressing without a border, up to 3 non-impregnated gauze dressing changes per day are considered medically necessary, unless there is documentation that more frequent changes are medically necessary.  For dressing changes with a border, one change per day is considered medically necessary, unless more frequent changes are medically necessary.  It is usually not considered medically necessary to stack more than 2 gauze pads on top of each other in any one area.

Gauze, impregnated, other than water or normal saline:

Note: Impregnated gauze dressings are woven or non-woven materials in which substances such as iodinated agents, petrolatum, zinc compounds, crystalline sodium chloride, chlorhexadine gluconate (CHG), bismuth tribromophenate (BTP), water, aqueous saline, or other agents have been incorporated into the dressing material by the manufacturer.  However, when the dressing and the substance with which it is impregnated are listed in combination in the FDA Orange Book (e.g., an antibiotic impregnated dressing which requires a prescription), then the entire item is considered a drug which would be covered under the pharmacy benefit if self-administered, ordered by a physician and available by prescription. 

Up to one dressing change per day is considered medically necessary for gauze dressings impregnated with other than water or normal saline, unless there is documentation that more frequent changes are medically necessary.

Gauze, impregnated, water or normal saline:

There is no medical necessity for these dressings compared to non-impregnated gauze which is moistened with bulk saline or sterile water. Note: Bulk saline or sterile water is not covered.

Hydrocolloid dressing:

Hydrocolloid dressings are considered medically necessary for use on wounds with light to moderate exudate.  Up to 3 dressing changes per week are considered medically necessary for hydrocolloid wound covers or hydrocolloid wound fillers, unless it is documented that more frequent changes are medically necessary.

Hydrogel dressing:

Hydrogel dressings are considered medically necessary when used on full thickness wounds with minimal or no exudate (e.g., stage III or IV ulcers). Hydrogel dressings are typically of no proven benefit 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).  For hydrogel wound covers without adhesive borders, up to one dressing change per day is considered medically necessary, unless it is documented that more frequent dressing changes are medically necessary.  For hydrogel wound covers with adhesive borders, up to 3 dressing changes per week are considered medically necessary, unless it is documented that more frequent changes are medically necessary.

The medically necessary quantity of hydrogel filler used for each wound should not exceed the amount needed to line the surface of the wound. Additional amounts used to fill a cavity are not considered medically necessary. Documentation must substantiate the medical necessity for hydrogel filler billed in excess of 3 units (fluid ounces) per wound in 30 days.

Use of both a hydrogel filler and a hydrogel cover on the same wound at the same time is of no proven benefit.

Specialty absorptive dressing:

Specialty absorptive dressings are unitized multi-layer dressings which provide (a) either a semi-adherent quality or non-adherent layer, and (b) highly absorptive layers of fibers such as absorbent cellulose, cotton, or rayon.  These may or may not have an adhesive border.  Specialty absorptive dressings are considered medically necessary when used for moderately or highly exudative wounds (e.g., stage III or IV ulcers).  Up to one change of specialty absorptive dressing per day is considered medically necessary for a dressing without an adhesive border, and up to one dressing change every other day is considered medically necessary for a dressing with a border, unless it is documented that more frequent changes are medically necessary.

Transparent film:

Transparent film dressings are considered medically necessary when used on open partial thickness wounds with minimal exudate or closed wounds.  Up to 3 transparent film dressing changes per week are considered medically necessary, unless it is documented that more frequent dressing changes are medically necessary.

Wound filler, not elsewhere classified:

Up to one dressing change per day is considered medically necessary, unless it is documented that more frequent changes are needed.

Wound pouch:

A wound pouch is a waterproof collection device with a drainable port that adheres to the skin around a wound.  Up to 3 dressing changes per week are considered medically necessary, unless the medical necessity of more frequent changes is documented.

Tape:

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

Elastic bandage:

Elastic bandages are considered medically necessary when used as a secondary dressing to hold wound cover dressings in place. When an elastic bandage is used over a wound cover with adhesive border or over a wound cover which is held in place by tape, elastic roll gauze or non-elastic roll gauze, or transparent film, the elastic bandage is of no proven benefit. Elastic bandages have also not been proven useful for strains, sprains, edema, or situations other than as a secondary surgical dressing.

Most elastic bandages are reusable.  No more than one replacement per week is considered medically necessary, unless the medical necessity of more frequent replacements is documented.

Gauze, elastic:

The medically necessary frequency of elastic gauze dressing changes is determined by the frequency of changes of the selected primary dressing. Overlying elastic gauze is of no proven benefit when a dressing is secured with tape or has an adhesive border.

Gauze, non-elastic:

The medically necessary frequency of non-elastic gauze dressing changes is determined by the frequency of change of the selected primary dressing. Overlying non-elastic gauze is of no proven benefit when a dressing is secured with tape or has adhesive border.

Notes on relationship with other policies:

Note: Under both HMO and traditional plans, charges for disposable supplies and accessories may also be covered when required to operate durable medical equipment or prosthetic devices (e.g., tracheostomy supplies, urologic supplies, ostomy supplies, dialysis supplies, etc.).

This policy is based in part upon Medicare DMERC criteria.

Staging of pressure ulcers:

The staging of pressure ulcers is as follows: