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    v1.0.28
    OpenPayerPolicy UpdatesPlastic/Reconstructive SurgeryAmbetter Nevada Burn Surgery Coverage | OpenPayer
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    CurrentAmbetter NevadaPolicy CP.MP.186

    Burn Surgery

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    This policy establishes medical necessity criteria for burn debridement and/or excision during the acute treatment phase. It applies to providers treating members of health plans affiliated with Ambetter Nevada/Centene; skin substitutes for burn treatment are addressed under CP.MP.185.

    Policy Summary
    PayerAmbetter Nevada
    PolicyBurn Surgery
    Policy CodePolicy CP.MP.186
    Change TypeMaterial revision
    Effective DateN/A
    Last ReviewSep 1, 2026
    Next Review DateN/A
    Key ActionConfirm that the burn is deep partial-thickness or full-thickness/deeper, because other burn depths do not meet criteria.
    SourceLink
    POLICY UPDATE CHANGES

    The description was revised in May 2026 to exclude skin grafting from this policy.

    The May 2026 revision removed CPT codes 15271 through 15278 and the HCPCS code table.

    The May 2026 revision removed skin graft information from the background.

    The September 2026 annual review updated the background and reviewed codes and descriptions without changing the coverage criteria.

    2Qualifying burn-depth categories

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    6Supporting CPT codes
    >20% TBSASevere-burn TBSA threshold
    29,165Annual inpatient burn admissions

    Acute Burn Debridement and Excision

    Acute burn debridement and/or excision

    Burn treatment with debridement and/or excision is medically necessary when either of the following is met:

    ONE of

    • Deep partial-thickness burn: The patient has a deep partial-thickness burn.
    • Full-thickness or deeper burn: The patient has a full-thickness burn or deeper.

    Codes and Clinical Thresholds

    Covered CPT CodesCPTCovered
    11000Debridement of extensive eczematous or infected skin; up to 10% of body surface.
    11042Debridement, subcutaneous tissue (includes epidermis and dermis, if performed); first 20 sq cm or less.
    11043Debridement, muscle and/or fascia (includes epidermis, dermis, and subcutaneous tissue, if performed); first 20 sq cm or less.
    11044Debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if performed); first 20 sq cm or less.
    11046Debridement, muscle and/or fascia (includes epidermis, dermis, and subcutaneous tissue, if performed); each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure).
    11047Debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if performed); each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure).
    Severe or Major Burn TBSA
    TBSA thresholdGenerally more than 20% of total body surface area (TBSA)
    ExclusionFirst-degree burns are excluded from the TBSA calculation

    Provider Guidance

    Denial Risk

    Confirm qualifying burn depth

    Burn debridement and/or excision does not meet this policy’s medical necessity criteria when the burn is not deep partial-thickness, full-thickness, or deeper.

    Burn Treatment Context

    Burns are traumatic injuries to the skin or other organic tissue caused primarily by heat, electrical discharge, friction, chemicals, or radiation. Burn depth ranges from superficial injury involving the epidermis to deeper injury extending through the skin and potentially into subcutaneous tissue, fascia, muscle, tendon, or bone. According to the American Burn Association, burn injuries result in approximately 29,165 inpatient admissions annually in the United States and are a leading cause of accidental injury and death; the most severe injuries may require care in a specialty hospital or burn center.

    Severe or major burns may be associated with major trauma, inhalation injury, chemical or high-voltage electrical exposure, involvement of more than 20% of total body surface area excluding first-degree burns, high-risk anatomic sites, or circumferential involvement. Early excision and closure of necrotic tissue may reduce hospital length of stay and the risks of hypertrophic scarring, contracture, infection, and stiffness. Burn surgery also presents challenges related to tissue loss, exposure of underlying structures, scarring, and limited tissue pliability.

    Burn Classification Definitions

    Burn
    DefinitionA traumatic injury to the skin or other organic tissue primarily caused by heat or exposure to electrical discharge, friction, chemicals, or radiation.
    Common causesHeat, electrical discharge, friction, chemicals, and radiation
    Tissue affectedSkin or other organic tissue
    Partial-Thickness Burn
    DefinitionA burn extending deeper into the dermis; the policy describes second-degree burns as partial-thickness burns.
    Typical featuresBlisters and a wet appearance
    Symptoms and healing
    Policy Summary
    PayerAmbetter Nevada
    PolicyBurn Surgery
    Policy CodePolicy CP.MP.186
    Change TypeMaterial revision
    Effective DateN/A
    Last ReviewSep 1, 2026
    Next Review DateN/A
    Key ActionConfirm that the burn is deep partial-thickness or full-thickness/deeper, because other burn depths do not meet criteria.
    SourceLink
    On This Page
    Acute Burn Debridement and ExcisionCodes and Clinical ThresholdsProvider GuidanceBurn Treatment ContextBurn Classification Definitions
    Typically extremely painful and may take two to three weeks to heal
    Full-Thickness Burn
    DefinitionA burn extending through the full depth of the skin.
    AppearanceOften white or leathery and dry to the touch
    SensationOften without sensation due to nerve damage
    Deeper injuryThe most severe burns may extend into subcutaneous tissue, fascia, muscle, tendon, or bone.
    Severe or Major Burn
    TBSA criterionGenerally more than 20% of total body surface area (TBSA), excluding first-degree burns
    Associated trauma or injuryMay be accompanied by major trauma, inhalation injury, or a chemical or high-voltage electrical burn
    High-risk individualsBurns may be considered severe at less than 20% TBSA in older adults, young children, or people with a major comorbidity
    High-risk sitesBurns involving the eyes, ears, face, hands, feet, or perineum may require specialized burn center care due to risk of functional impairment
    Circumferential burnsCircumferential burns of the extremities or thorax require consultation with a burn center