CurrentAetnaPolicy 0062

Burn Garments

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Defines Aetna's medical necessity, investigational status, and coverage limitations for burn garments and related therapies for members with burns at risk for hypertrophic scarring or contracture.

Policy Summary

PayerAetna

PolicyBurn Garments

Policy CodePolicy 0062

Change TypeNo material changes

Effective DateOct 23, 1995

Last ReviewMar 17, 2023

Next Review DateJan 11, 2024

Key ActionObtain prior authorization and document that the burn places the member at risk of contracture and that the garment and therapies are intended to prevent grafting or contracture.

SourceLink

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CurrentAetnaPolicy 0062

Burn Garments

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Get alerted when Policy 0062 changes without checking for updates manually.

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Defines Aetna's medical necessity, investigational status, and coverage limitations for burn garments and related therapies for members with burns at risk for hypertrophic scarring or contracture.

Policy Summary

PayerAetna

PolicyBurn Garments

Policy CodePolicy 0062

Change TypeNo material changes

Effective DateOct 23, 1995

Last ReviewMar 17, 2023

Next Review DateJan 11, 2024

Key ActionObtain prior authorization and document that the burn places the member at risk of contracture and that the garment and therapies are intended to prevent grafting or contracture.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6 trials / 316meta-analysis sample

1–2 yrstypical duration

24–40 mmHgtherapeutic pressures

10/23/1995effective date

01/11/2024next review

Coverage Criteria for Burn Garments

Medical Necessity

Aetna considers burn garments and associated physical and occupational therapy medically necessary when ALL of the following criteria are met:

Main medical necessity criteria

The burn is of documented significance to place the member at risk of a post-burn contracture.
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.
The burn garment is authorized by the primary care physician and/or the treating specialist.

HCPCS coverage condition

HCPCS codes are covered only if selection criteria are met:

HCPCS selection

Selected HCPCS (A65xx) are covered only when the policy's selection criteria and authorization requirements are satisfied.
HCPCS A6025 (gel sheet for dermal or epidermal application, e.g., silicone, hydrogel) is not covered as an adjunct to pressure garment therapy.

The policy lists certain interventions that are considered experimental and investigational because their effectiveness has not been established. Specifically, the use of support garments for scar minimization of the donor site is identified as investigational, and topical silicone gel used as an adjunct to pressure garment therapy is also considered investigational and not proven to improve clinical outcomes.

This Clinical Policy Bulletin is intended to provide a partial, general description of plan or program benefits and to assist in administering those benefits. It does not constitute a contract, an offer of coverage, or medical advice. Coverage determinations are governed by the member’s specific plan or program provisions, and treating providers remain solely responsible for medical care and treatment decisions.

Interim or low-pressure support garments designed for donor-site scar minimization are noted to be poorly documented in the literature. The policy states that such interim pressure garments (example trial pressures of 4–6 mmHg) lack sufficient rigorous clinical evidence and therefore are considered experimental and investigational until more conclusive data are available.

Coding and Pressure Details

Not covered HCPCSHCPCSNot Covered

A6025

Gel sheet for dermal or epidermal application (e.g., silicone, hydrogel, other) — Not covered as adjunct to pressure garment therapy

Pressure range examples — interim garment trial and typical therapeutic garment pressures

Interim garment trial4–6 mmHg (low-pressure interim pressure garment studied for donor sites)

Typical therapeutic garment pressure range24–40 mmHg (medium to high pressures commonly used for scar minimization)

Recommended duration contextPGT often prescribed for prolonged periods (commonly 1–2 years), with benefits lost if therapy is stopped early)

HCPCS A65xx codes — custom-fabricated compression burn garments and accessories

A6501Compression burn garment, bodysuit (head to foot), custom fabricated

A6504 - A6508

Provider Actions, Authorization, and Documentation

Prior Authorization

Prior Authorization Required

Prior authorization is required for burn garment HCPCS codes. The compression burn garment must be authorized by the member’s primary care physician and/or the treating specialist and meet the medical necessity criteria in this policy (documented risk of post-burn contracture; intent to prevent grafting or contractures from hypertrophic scarring).

Prior authorization required for HCPCS burn garment codes listed in this policy.
Authorization must be by the PCP and/or treating specialist and supported by clinical documentation.

Note

Clinical Policy Bulletins Are Not Offers

Treating providers are solely responsible for medical advice and treatment decisions. Clinical Policy Bulletins are developed to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract.

Background and Evidence Summary

Pressure garment therapy (PGT) is the application of compressive garments to healing burn scars with the intent of reducing hypertrophy, scar height, and the risk of contracture while improving scar appearance and function. PGT is commonly prescribed for burns on high-tension areas (for example, chest, face, hands, joints, and upper legs) and typically requires prolonged outpatient follow-up with frequent early visits and long-term garment use, often for many months to a year or longer. Evidence for PGT is limited and mixed: studies document the use of medium-to-high pressures (commonly around 24–40 mmHg) and show variable benefit for scar outcomes, while trials of adjunctive therapies (such as silicone combined with pressure) have not demonstrated clear additional clinical benefit.

Definitions

Pressure Garment Therapy (PGT) — definition

DefinitionApplication of compressive garments to healing burn scars to reduce hypertrophy, scar height, contracture risk, and improve scar appearance and function.

PurposeUsed to preserve function and appearance during healing, especially on high-tension areas (chest, face, hands, joints, upper legs).

Care pathwayFollow-up is outpatient with frequent early visits and prolonged use until scar maturation (commonly about 12 months or longer).

Pressure garment therapy (PGT) — alternate/duplicate definition

Alternate definitionUse of compressive garments to prevent or manage hypertrophic scarring following burns, including custom and interim garments and combinations with silicone (though silicone adjuncts lack proven added benefit).

Evidence note

Revision History

Policy Summary

PayerAetna

PolicyBurn Garments

Policy CodePolicy 0062

Change TypeNo material changes

Effective DateOct 23, 1995

Last ReviewMar 17, 2023

Next Review DateJan 11, 2024

Key ActionObtain prior authorization and document that the burn places the member at risk of contracture and that the garment and therapies are intended to prevent grafting or contracture.

SourceLink

On This Page

Compression burn garment, glove to wrist; glove to elbow; glove to axilla; foot to knee; foot to thigh — custom fabricated (individual garment codes)

A6509 - A6513Upper trunk to waist (vest), trunk/leotard, lower trunk, not otherwise classified, compression burn mask — custom fabricated

Documentation Required

DME Coverage Note

Burn garments are considered durable medical equipment (DME). Coverage for DME varies by benefit plan; verify the member’s benefit plan for DME coverage details before ordering and document authorization and benefit determinations in the medical record.

Check the member’s benefit plan for DME coverage details prior to procurement.
Document benefit verification and any authorization in the patient’s record.

Denial Risk

Denial Triggers and Documentation Requirements

Denials may result if medical necessity criteria are not met or if HCPCS codes are billed for indications not supported by the policy (for example, use of gel sheets as an adjunct to pressure garment therapy is listed as not covered). Ensure documentation demonstrates burn significance, risk of contracture, treatment intent, and authorization source to reduce denial risk.

Denial triggers include missing evidence of risk for contracture, lack of intent to prevent grafting/contracture, or HCPCS billed for unsupported indications.
Document clinical findings, treatment intent, authorization by PCP/specialist, and benefit verification.

Documentation Required

Required Clinical Documentation

Providers must document the clinical significance of the burn, objective evidence of risk for post-burn contracture, and that the garment and therapies are intended to prevent grafting or contractures from hypertrophic scarring. Include dates, location and extent of burns, functional limitations, prior treatments, and the authorizing clinician’s name and specialty.

Document burn site(s), depth/extent, % total body surface area if available, and functional impact.
Document rationale that garment/therapy aim to prevent contracture or skin grafting and identify the authorizing PCP or treating specialist.

Note

Administrative Disclaimer

Administrative and contractual deficiencies (for example, missing prior authorization, incomplete benefit verification, or incomplete clinical documentation) may lead to claim denial even when clinical criteria are met. This Clinical Policy Bulletin may be updated and is subject to change.

Verify prior authorization and benefit specifics before delivery.
Maintain complete records of authorization, clinical rationale, and benefit determinations.

Evidence for effectiveness is limited and mixed; PGT is commonly used but associated with low compliance and variable outcomes.

Clinical applicationMedium-to-high pressures (24–40 mmHg) support scar minimization; low-pressure interim garments (4–6 mmHg) are under study for donor sites.