Burn Surgery (PDF)
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Defines medical necessity criteria for burn debridement/excision and the use/application of skin replacements/skin substitutes during the acute phase of burn treatment for members/enrollees of Centene-affiliated health plans.
Added medical necessity criteria for debridement/excision and skin substitutes.
Added acceptable tissue engineered products (Apligraf, TheraSkin, Integra wound matrix, Biobrane, Transcyte).
Added criteria that burn must be deep partial-thickness or full-thickness (II.C).
Coding reviewed and updated; code table titles changed from 'coverage' to 'medical necessity'.
Annual background and reference updates and minor wording changes with no clinical significance.
Coverage Summary
Policy number CP.MP.186 (Clinical Policy: Burn Surgery) is CURRENT and defines medical necessity criteria for acute-phase burn debridement/excision and the use/application of skin replacements/skin substitutes for members/enrollees of Centene-affiliated health plans. The policy specifies that burn treatment with debridement and/or excision is medically necessary for deep partial-thickness burns or full-thickness burns or deeper and that skin replacement/substitutes are medically necessary only when all specified criteria are met.
Per the policy (last reviewed 11/25), skin replacement/substitutes are covered with criteria when: sufficient autograft is not available or is not feasible, there is no evidence of burn wound infection, the burn is deep partial-thickness or full-thickness, and treatment is with an acceptable product (allograft, xenograft, or a tissue-engineered skin substitute used according to FDA indications, with Epicel acceptable only if used per FDA HDE requirements).
Medical Necessity Criteria
Medically Necessary: Debridement and/or Excision
Burn treatment with debridement and/or excision is medically necessary for either of the following:
ANY of the following
- Deep partial-thickness burn
- Full-thickness burn or deeper
Medically Necessary: Skin Replacement/Substitutes (including procedure, product, service)
Skin replacement/substitutes are medically necessary when ALL of the following are met:
ALL of the following
- Sufficient autograft is not available at the time of excision or is not feasible due to the physiological condition of the member/enrollee
- No evidence of burn wound infection
- Burn is either deep partial-thickness or full-thickness
ALL of the following
ONE OF
- Allograft (human cadaver)
- Xenograft (porcine)
- Tissue-engineered skin substitute used according to FDA indications (examples: Biobrane, Transcyte, Apligraf, TheraSkin, Integra Wound Matrix, Integra meshed Bilayer Wound Matrix, Integra Dermal Regeneration Template, or Epicel if used per FDA HDE)
- If Epicel is used, it must be used per FDA Humanitarian Device Exemption (HDE) requirements
Provider Actions & Documentation Requirements
Document lack of available autograft or physiologic infeasibility
Document that sufficient autograft is not available at the time of excision or that autograft is not feasible due to the member/enrollee's physiological condition.
Document absence of burn wound infection
Document that there is no evidence of burn wound infection prior to using skin replacement/substitutes.
Document burn depth
Document that the burn is deep partial-thickness or full-thickness to support debridement/excision and use of skin substitutes.
Epicel usage constraint
Epicel must be used in accordance with FDA Humanitarian Device Exemption (HDE) requirements and documentation of conformity with the HDE must be provided when Epicel is billed or used.
- If Epicel billed, document HDE conformity
Coding (Codes that support medical necessity)
| 11000 | Debridement of extensive eczematous or infected skin; up to 10% of body surface. |
| 11042 | Debridement, subcutaneous tissue (includes epidermis and dermis, if performed); first 20 sq cm or less. |
| 11043 | Debridement, muscle and/or fascia (includes epidermis, dermis, and subcutaneous tissue, if performed); first 20 sq cm or less. |
| 11044 | Debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if performed); first 20 sq cm or less. |
| 11046 | Debridement, 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). |
| 11047 | Debridement, 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). |
| 15271 | Application of skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area. |
| 15272 | Application of skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; each additional 25 sq cm wound surface area, or part thereof (List separately in addition to code for primary procedure). |
| 15273 | Application of skin substitute graft to trunk, arms, legs, total wound surface area greater than or equal to 100 sq cm; first 100 sq cm wound surface area, or 1% of body area of infants and children. |
| 15274 | Application of skin substitute graft to trunk, arms, legs, total wound surface area greater than or equal to 100 sq cm; each additional 100 sq cm wound surface area, or part thereof, or each additional 1% of body area of infants and children, or part thereof (List separately in addition to code for primary procedure). |
| 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. |
Background
Early debridement and early grafting are emphasized as vital to survivability and improved outcomes in burn patients; early excision and grafting reduce hospital length of stay, risk of hypertrophic scarring, joint contracture, infection, stiffness, and mortality. The policy addresses these acute-phase interventions and notes that early excision provides a skin substitute for the wound while additional reconstructive surgery may still be required.
Autografts (split- or full-thickness skin grafts) are stated as the current standard of care. When autograft is unavailable—for example, when total body surface area burned exceeds available donor sites or tissues are too edematous for successful autograft—alternatives include allografts (human cadaver), xenografts (porcine), and tissue-engineered skin substitutes, which may be used either temporarily or permanently to replace skin form and function.
Revision History
New policy adapted from WellCare HS321; added medical necessity criteria for debridement/excision and skin substitutes; added acceptable tissue-engineered products (Apligraf, TheraSkin, Integra wound matrix, Biobrane, Transcyte); Epicel acceptable if used per FDA HDE.
Removed ICD-10 codes; references reviewed and updated; replaced 'member' with 'member/enrollee'.
Annual review completed; background updated and minor rewording with no clinical significance; references reviewed, reformatted and updated.
Annual review: Added criterion II.C specifying burn must be deep partial-thickness or full-thickness; added 'used according to FDA indications' to II.D.3; references reviewed and updated.
Annual review: References reviewed and updated; reviewed by external specialist.
Annual review: Description and background updated with no clinical significance; clarified HDE abbreviation in II.D.3; coding reviewed and updated; code table titles changed from 'coverage' to 'medical necessity'.
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