CurrentArizona Complete HealthPolicy CP.MP.186

Burn Surgery (PDF)

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.

Policy Summary

PayerArizona Complete Health

PolicyBurn Surgery (PDF)

Policy CodePolicy CP.MP.186

Change TypeAdded/revised medical necessity criteria

Effective Date

Next Review Date

Key ActionProvider must document that sufficient autograft is not available or not feasible, document absence of burn wound infection, and document burn depth (deep partial-thickness or full-thickness).

SourceLink

POLICY UPDATE CHANGES

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.

2Primary burn depth indications (deep partial-thickness, full-thickness)

≥1Tissue-engineered products listed as examples

18Referenced sources in bibliography

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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).

Statistics

Primary burn depth indications (deep partial-thickness, full-thickness)2

Tissue-engineered products listed as acceptable examples≥1

Referenced sources in bibliography18

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

Provider Actions & Documentation Requirements

Documentation Required

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.

Documentation Required

Document absence of burn wound infection

Document that there is no evidence of burn wound infection prior to using skin replacement/substitutes.

Documentation Required

Document burn depth

Document that the burn is deep partial-thickness or full-thickness to support debridement/excision and use of skin substitutes.

Coding (Codes that support medical necessity)

CPT codes that support medical necessity criteriaCPTCovered

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).

1–10 of 14

1/2

HCPCS codes that support medical necessity criteria (skin substitutes)HCPCSCovered

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.

Definitions

Burn depthsDeep partial-thickness and full-thickness burns are specified as indications for debridement/excision and skin substitutes.

Epicel HDEEpicel is acceptable if used in accordance with FDA Humanitarian Device Exemption requirements.

Revision History

05/20policy_adoption

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.

05/21coding_and_text_update

Removed ICD-10 codes; references reviewed and updated; replaced 'member' with 'member/enrollee'.

11/22annual_review