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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 debridement and/or excision during the acute treatment of burns. It applies to providers treating members/enrollees of Ambetter Nevada health plans.

    Policy Summary
    PayerAmbetter Nevada
    PolicyBurn Surgery
    Policy CodePolicy CP.MP.186
    Change TypeMaterial revision
    Effective Date09/01/2026
    Last ReviewMay 1, 2026
    Next Review DateNot specified
    Key ActionVerify that the burn is deep partial-thickness or full-thickness/deeper before submitting debridement or excision for coverage.
    SourceLink
    POLICY UPDATE CHANGES

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

    The prior skin-substitute criteria were removed from this policy and moved to CP.MP.185 Skin and Soft Tissue Substitutes.

    CPT codes 15271 through 15278 and the HCPCS code table were removed.

    2Burn-depth indications meeting medical necessity
    6Listed CPT debridement codes

    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.

    Deep partial-thickness+Minimum burn depth addressed
    1Related skin-substitute policy

    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

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

    Codes Supporting Medical Necessity

    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)

    Provider Action

    Denial Risk

    Confirm qualifying burn depth

    Ensure the burn is documented as either a deep partial-thickness burn or a full-thickness burn or deeper. Burn treatment with debridement and/or excision is medically necessary only when one of these depth criteria is met.

    • Deep partial-thickness burn
    • Full-thickness burn or deeper

    Burn Overview

    Burns are traumatic injuries to the skin or other organic tissue caused primarily by heat, electrical discharge, friction, chemicals, or radiation. They range from superficial and partial-thickness injuries to full-thickness burns extending through the skin and deeper injuries involving muscle, tendons, or bone.

    Severe or major burns generally involve more than 20% of total body surface area, excluding first-degree burns, or are associated with major trauma, inhalation injury, chemical exposure, or high-voltage electrical injury. Smaller burns may also be severe in high-risk individuals or when they affect functionally critical areas such as the eyes, ears, face, hands, feet, or perineum.

    This policy addresses medical necessity for debridement and/or excision during the acute phase of burn treatment.

    Burn Definitions

    Partial-thickness burn
    DepthExtends deeper into the dermis.
    Typical appearanceIncludes blisters and has a wet appearance.
    ClassificationAlso called a second-degree burn.
    Symptoms and healingExtremely painful and may take two to three weeks to heal.
    Full-thickness burn
    DepthExtends through the full depth of the skin.
    Typical appearanceHas a white or leathery appearance and is dry to the touch.
    Policy Summary
    PayerAmbetter Nevada
    PolicyBurn Surgery
    Policy CodePolicy CP.MP.186
    Change TypeMaterial revision
    Effective Date09/01/2026
    Last ReviewMay 1, 2026
    Next Review DateNot specified
    Key ActionVerify that the burn is deep partial-thickness or full-thickness/deeper before submitting debridement or excision for coverage.
    SourceLink
    On This Page
    Acute Burn Debridement and ExcisionCodes Supporting Medical NecessityProvider ActionBurn OverviewBurn Definitions
    ClassificationAlso called a third-degree burn.
    SensationOften lacks sensation because of nerve damage.
    Deeper burn
    Tissue involvementExtends into deep tissues beyond the skin.
    Structures affectedMay extend into muscle, tendons, and/or bone.
    ClassificationCalled a fourth-degree burn or a burn with extension to deep tissues.
    Treatment implicationSkin grafting and more intensive surgeries or amputations may be required for healing.
    Severe or major burn
    General thresholdGenerally involves more than 20% of total body surface area, excluding first-degree burns.
    Qualifying circumstancesMay be accompanied by major trauma, inhalation injury, chemical injury, or high-voltage electrical injury.
    High-risk individualsBurns may be severe even when less than 20% of total body surface area is involved in older adults, young children, or people with a major comorbidity.
    Critical anatomic areasBurns involving the eyes, ears, face, hands, feet, or perineum may require specialized burn-center care because of the risk of functional impairment.
    Circumferential burnsCircumferential burns of the extremities or thorax require burn-center consultation because they may decrease blood flow; deep circumferential chest burns may impair or prevent mechanical ventilation.