CurrentAmbetter NevadaPolicy CP.MP.186

Clinical Policy: Burn Surgery

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Medical necessity criteria for burn debridement/excision and use/application of skin replacements and skin substitutes during the acute phase of burn treatment for Ambetter Nevada members.

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CurrentAmbetter NevadaPolicy CP.MP.186

Clinical Policy: Burn Surgery

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Medical necessity criteria for burn debridement/excision and use/application of skin replacements and skin substitutes during the acute phase of burn treatment for Ambetter Nevada members.

Policy Summary

PayerAmbetter Nevada

PolicyClinical Policy: Burn Surgery

Policy CodePolicy CP.MP.186

Change TypeAnnual review — no material changes

Effective Date

Last ReviewNov 25, 2024

Next Review Date

Key ActionObtain prior authorization when required and submit documentation of burn depth, autograft availability/infeasibility, infection status, and wound surface area.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

CPT & HCPCSprocedure and product codes provided

Deep partial/fullburn depth required

No infectioninfection requirement

Autograft unavailableautograft requirement

I–IIpolicy sections

Coverage Criteria

Debridement / Excision

Covered when ANY of the following are met:

Debridement/excision indication: Deep partial-thickness burn

per policy I.A

Debridement/excision indication: Full-thickness burn or deeper

per policy I.B

Skin replacement / substitutes

Covered when ALL of the following are met:

Autograft availability: Sufficient autograft is not available at the time of excision or is not feasible due to the physiological condition of the member/enrollee

policy II.A

Infection status: No evidence of burn wound infection

policy II.B

Burn depth: Burn is either deep partial-thickness or full-thickness

policy II.C

Accepted products: Treatment is with an accepted skin replacement/substitute (e.g., allograft, xenograft, or FDA-indicated tissue-engineered products such as Biobrane, Transcyte, Apligraf, TheraSkin, Integra matrices, Epicel if used per FDA HDE)

policy II.D

The policy revision removed prior language that explicitly labeled investigational products or procedures as not medically necessary. Revision notes document that statements excluding investigational products/procedures were removed and that acceptable tissue-engineered products (for example, Apligraf, TheraSkin, Integra wound matrix, Biobrane, TransCyte, and Epicel when used per FDA HDE requirements) were added to the medical necessity criteria. The revision history records these changes and clarifies that the policy now specifies medical necessity criteria for debridement/excision and skin substitutes rather than maintaining a blanket investigational exclusion.

When this clinical policy conflicts with applicable state Medicaid coverage provisions, the state Medicaid requirements take precedence. The Health Plan’s coverage determinations and administration of benefits must also comply with all applicable state and federal requirements and the member’s evidence of coverage or certificate of coverage.

Earlier versions of the policy included a provision stating that burn surgery was not medically necessary when duplicating another provider’s procedure, product, or service. That criterion was removed in subsequent revisions; revision notes indicate removal of the prior "not medically necessary" statements that labeled duplicative or investigational treatments as excluded.

Procedure and Product Coding

Covered CPT CodesCPTCovered

11000	Debridement of extensive eczematous or infected skin; up to 10% of body surface.
11042	Debridement, subcutaneous tissue; first 20 sq cm or less.
11043	Debridement, muscle and/or fascia; first 20 sq cm or less.
11044	Debridement, bone; first 20 sq cm or less.
11046	Debridement, muscle and/or fascia; each additional 20 sq cm, or part thereof.
11047	Debridement, bone; each additional 20 sq cm or part thereof.
15271	Application of skin substitute graft to trunk/arms/legs up to 100 sq cm; first 25 sq cm or less.
15272	Application of skin substitute graft to trunk/arms/legs up to 100 sq cm; each additional 25 sq cm.
15273	Application of skin substitute graft to trunk/arms/legs >=100 sq cm; first 100 sq cm, or 1% body area infants/children.
15274	Application of skin substitute graft to trunk/arms/legs >=100 sq cm; each additional 100 sq cm or 1% body area.

1–10 of 14

1/2

Covered HCPCS CodesHCPCSCovered

Q4100	Skin substitute, not otherwise specified.
Q4101	Apligraf, per sq cm.
Q4104	Integra bilayer matrix wound dressing (BMWD), per sq cm.
Q4105	Integra dermal regeneration template (DRT) or Integra Omnigraft dermal regeneration matrix, per sq cm.
Q4108	Integra matrix, per sq cm.
Q4121	TheraSkin, per sq cm.
Q4182	TransCyte, per sq cm.
C9363	Skin substitute (Integra Meshed Bilayer Wound Matrix), per sq cm.

Wound surface area coding thresholds — 25 sq cm increments and pediatric conversion

Initial coding increment for skin substitute application (trunk/arms/legs)First 25 sq cm or less (CPT 15271) with each additional 25 sq cm or part thereof (CPT 15272)

Large-area coding for skin substitute application (trunk/arms/legs)First 100 sq cm, or 1% body area of infants/children (CPT 15273); each additional 100 sq cm or 1% body area (CPT 15274)

Initial coding increment for face/scalp/hand/etc. sitesFirst 25 sq cm or less (CPT 15275) with each additional 25 sq cm or part thereof (CPT 15276)

Large-area coding for face/scalp/hand/etc. sitesFirst 100 sq cm, or 1% body area of infants/children (CPT 15277); each additional 100 sq cm or 1% body area (CPT 15278)

Pediatric conversion for large woundsWhen total wound surface area is ≥100 sq cm, pediatric measurement may be reported as 1% of body area for infants and children (applies to CPT 15273–15278)

Provider Actions and Documentation Requirements

Prior Authorization

Prior Authorization and Documentation

Prior Authorization Required: Prior authorization may be required for burn debridement, skin grafting, and use of skin substitutes/allografts/xenografts/tissue-engineered products. Submit supporting clinical documentation with the prior authorization request demonstrating that the medical necessity criteria are met (see Policy/Criteria): depth of burn (deep partial-thickness or full-thickness), availability/feasibility of autograft, and absence of wound infection.

Affected CPT/HCPCS: include appropriate codes from CPT 11000 series, 15271–15278 and HCPCS Q4100–Q4121, Q4182, C9363 as applicable.
Documentation must describe wound depth, %TBSA or wound surface area, autograft availability/feasibility, and infection status.

Denial Risk

Autograft Requirement and Denial Conditions

Policy requires that autograft be used when sufficient autograft is available and feasible prior to using allograft, xenograft, or tissue‑engineered skin substitutes. Requests for skin replacement/substitute will be denied when an autograft is available/feasible, when there is evidence of wound infection, or when other policy exclusions apply.

Background and Clinical Context

Burn injuries are categorized by depth from superficial to fourth-degree, with increasing tissue involvement and need for surgical management. Partial-thickness (second-degree) burns extend into the dermis, often present with blistering and a moist appearance, and may heal in two to three weeks but can require surgical management if deep. Full-thickness (third-degree) burns extend through the entire skin thickness, typically appear white or leathery and may be insensate due to nerve damage; these burns commonly require skin grafting. Deeper burns (third- and fourth-degree) more often require early excision and grafting to reduce complications and length of stay; debridement and excision are standard surgical interventions for deep partial-thickness and full-thickness injuries.

Definitions

Full-thickness burn (third-degree) — definition and clinical features

DefinitionFull-thickness (third-degree) burns extend the full depth of the skin and often require skin grafts.

AppearanceWhite or leathery appearance and dry to the touch.

SensationOften insensate due to nerve damage.

Typical managementSkin grafting is typically required for healing; may require admission to a burn center for severe injuries.

Partial-thickness burn (second-degree) — definition and clinical features

DefinitionPartial-thickness (second-degree) burns extend into the dermis and include blistering.

Policy Summary

PayerAmbetter Nevada

PolicyClinical Policy: Burn Surgery

Policy CodePolicy CP.MP.186

Change TypeAnnual review — no material changes

Effective Date

Last ReviewNov 25, 2024

Next Review Date

Key ActionObtain prior authorization when required and submit documentation of burn depth, autograft availability/infeasibility, infection status, and wound surface area.

SourceLink

On This Page

Autograft must be documented as unavailable or not feasible due to the member's physiological condition.
Denied when documentation shows autograft was available, infection is present, or exclusion criteria apply.

Documentation Required

Documentation Requirements

Documentation should support the selected procedure or product and include the applicable CPT/HCPCS codes, details of the burn (depth, size in sq cm or % body area, anatomical location), treatment history, and rationale for product selection (including why autograft is not available/feasible).

Include operative reports, pathology/intraoperative findings, prior treatment attempts, and culture results if infection is suspected.
List all CPT/HCPCS codes billed and link each to supporting clinical notes.

Note

Coverage Decisions and Regulatory Alignment

Coverage decisions and the administration of benefits are subject to all terms, conditions, exclusions and limitations of the member's coverage documents and to applicable state and federal requirements. For Medicaid members, state Medicaid provisions take precedence when they conflict with this clinical policy. For Medicare members, review applicable NCDs/LCDs prior to applying this policy.

Ensure claims and coverage decisions align with the member's evidence of coverage/certificate of coverage and the contract.
When conflicts exist for Medicaid members, follow state Medicaid manual provisions; for Medicare members, confirm consistency with CMS NCDs/LCDs.

Billing Rule

Provider Responsibilities for Claims and Coverage

Providers should ensure that claims submission, prior authorization requests, and coverage determinations reference the member's current evidence/certificate of coverage and applicable Health Plan administrative policies. Failure to provide required documentation or to follow plan/contract provisions may result in claim denials or non‑coverage.

Verify member eligibility and benefit coverage before submitting requests.
Include copies of prior authorizations, clinical notes, and operative documentation with claims when required.

Wet appearance with blisters; extremely painful.

Healing timeCan take two to three weeks to heal; deep partial-thickness may require surgical management.

Clinical implicationDepth may determine need for debridement/excision and possible grafting.

ISBI guidelines — Practice guideline reference

Guideline titleISBI Practice Guidelines for Burn Care (Burns. 2016;42(5):953–1021; Part 2 in Burns. 2018 Nov;44(7):1617–1706)

Developing bodyInternational Society for Burn Injury (ISBI) Practice Guidelines Committee and associated subcommittees.

Use in policyCited as the practice guideline reference supporting burn care recommendations in this clinical policy.