CurrentCapital BluecrossPolicy MP 2.033

Recombinant and Autologous Platelet-Derived Growth Factors as a Treatment of Wound Healing and Other Non‑Orthopedic Conditions

Customize your policy alerts

Sign up for Capital Bluecross Policy MP 2.033 alerts

Get alerted when Policy MP 2.033 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

This policy governs medical coverage for recombinant platelet-derived growth factor (becaplermin) and autologous platelet-rich plasma (PRP) when used to treat non-orthopedic wounds, specifying indications considered medically necessary versus investigational and candidate criteria for use.

Policy Summary

PayerCapital Bluecross

PolicyRecombinant and Autologous Platelet-Derived Growth Factors as a Treatment of Wound Healing and Other Non‑Orthopedic Conditions

Policy CodePolicy MP 2.033

Change TypeNo material change

Effective DateJul 1, 2026

Last ReviewMar 4, 2026

Next Review Date

Key ActionDocument planned frequency and duration (typically once daily for up to 20 weeks) and estimated quantity when requesting prior authorization for becaplermin.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

becaplermin approved indicationsCovered indications

investigationalPRP stance

>=30 mmHgOxygenation threshold

up to 20 wks

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.

CurrentCapital BluecrossPolicy MP 2.033

Recombinant and Autologous Platelet-Derived Growth Factors as a Treatment of Wound Healing and Other Non‑Orthopedic Conditions

Customize your policy alerts

Sign up for Capital Bluecross Policy MP 2.033 alerts

Get alerted when Policy MP 2.033 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

PayerCapital Bluecross

PolicyRecombinant and Autologous Platelet-Derived Growth Factors as a Treatment of Wound Healing and Other Non‑Orthopedic Conditions

Policy CodePolicy MP 2.033

Change TypeNo material change

Effective DateJul 1, 2026

Last ReviewMar 4, 2026

Next Review Date

Key ActionDocument planned frequency and duration (typically once daily for up to 20 weeks) and estimated quantity when requesting prior authorization for becaplermin.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

becaplermin approved indicationsCovered indications

investigationalPRP stance

>=30 mmHgOxygenation threshold

up to 20 wks

S0157/S9055Procedure codes

Coverage Criteria — Recombinant and Autologous Platelet-Derived Growth Factors

inv-01: Becaplermin — Diabetic Neuropathic Ulcers — Covered when ALL criteria are met

Covered when ALL of the following are met

Becaplermin coverage criteria for diabetic neuropathic ulcers: 1) Ulcer is a neuropathic diabetic lower-extremity ulcer extending into subcutaneous tissue; 2) Adequate tissue oxygenation, measured by transcutaneous partial pressure of oxygen (TcPO2) >= 30 mm Hg on the foot dorsum or at the margin of the ulcer; 3) Full-thickness ulcer (Stage III or IV) extending through the dermis into subcutaneous tissues; 4) Participation in a wound-management program including sharp debridement, pressure relief/non-weight bearing, and infection control; 5) Becaplermin is used as an adjunct to standard wound careTcPO2 >= 30 mm Hg

Based on policy statements specifying candidate criteria and adjunctive use.

inv-02: Becaplermin — Pressure Ulcers — Covered when ALL criteria are met

Covered when ALL of the following are met

Becaplermin coverage criteria for pressure ulcers: 1) Full-thickness ulcer (Stage III or IV) extending through the dermis into subcutaneous tissues; 2) Ulcer located in an anatomic site that can be off-loaded for the duration of treatment; 3) Albumin concentration > 2.5 dL; 4) Total lymphocyte count > 1,000/μL; 5) Normal values of vitamins A and C; 6) Participation in a wound-management program including debridement, off-loading, and infection control; 7) Becaplermin administered as adjunct to standard wound care (typical dosing once daily for up to 20 weeks)Albumin > 2.5 dL; Total lymphocyte count > 1,000/μL

Policy specifies typical treatment frequency, tube sizes, and application technique.

inv-04: Recombinant PDGF — Covered indications (diabetic neuropathic ulcers; pressure ulcers) — criteria for covered use

Covered when clinically appropriate for specific wound types

Covered indications: Recombinant PDGF (becaplermin) is covered when medically necessary for: 1) Neuropathic diabetic lower-extremity ulcers extending into subcutaneous tissue (supported by RCTs and systematic reviews showing improved healing); and 2) Pressure ulcers extending into subcutaneous tissue (supported by a randomized controlled trial showing improved healing). Procedure codes S0157 and S9055 apply when medically necessary; relevant ICD-10 diagnosis codes for diabetic foot ulcers and pressure ulcers are enumerated in the policy.

Evidence summary supports net health outcome improvement for these indications.

inv-06: Recombinant PDGF — Insufficient evidence for other wound types (not established/insufficient)

Not covered due to insufficient or mixed evidence

PRP investigational / not covered: Use of autologous blood-derived preparations (platelet-rich plasma, PRP) for treatment of acute or chronic wounds — including surgical wounds, non-healing ulcers, and chronic wounds (diabetic, venous, pressure) — is considered investigational and therefore not covered due to insufficient or inconsistent evidence (meta-analyses and small trials with risk of bias and imprecision).

Policy cites mixed trial results and insufficient evidence to determine net health benefit.

inv-03: Not Covered / Investigational — Top-level node indicating investigational uses

Uses considered investigational

Investigational / Not Covered uses: 1) Recombinant PDGF (becaplermin) applications other than neuropathic diabetic ulcers or pressure ulcers extending into subcutaneous tissue (examples: ischemic ulcers, venous stasis ulcers, ulcers not extending into subcutaneous tissue) are considered investigational and may be denied; 2) Autologous platelet-rich plasma (PRP) for acute or chronic wounds, surgical wounds, and non-healing ulcers is considered investigational and not covered.

Based on policy statement that other applications lack sufficient evidence.

inv-05: Autologous PRP — Investigational / Not Covered — criteria/exclusion node

Not covered due to insufficient or mixed evidence

Autologous PRP — Investigational / Not Covered: Use of autologous platelet-rich plasma (PRP) or other autologous blood‑derived preparations for treatment of acute or chronic wounds, including surgical wounds, diabetic lower‑extremity ulcers, venous ulcers, and pressure ulcers, is investigational and not covered because current evidence from meta-analyses and small trials is limited by risk of bias, imprecision, and inconsistent results and does not demonstrate a net health outcome benefit.

Coding section reiterates PRP is investigational; procedure codes are not listed for coverage.

Becaplermin (Regranex®) is indicated as an adjunct to standard wound care for lower‑extremity diabetic neuropathic ulcers that extend into the subcutaneous tissue and for pressure ulcers that extend into subcutaneous tissue; it is not intended for wounds that close by primary intention and its efficacy has not been established for diabetic ulcers that do not extend through the dermis into subcutaneous tissue or for ischemic diabetic ulcers. Documentation of adequate blood supply and participation in a wound‑management program (including sharp debridement, pressure relief/off‑loading, and infection control) is expected when considering becaplermin therapy. Typical candidate requirements include transcutaneous PO2 ≥ 30 mm Hg at the foot dorsum or ulcer margin and staging consistent with full‑thickness ulcers (Stage III/IV) that extend into subcutaneous tissue.

Use of autologous platelet‑rich plasma (PRP) for treatment of surgical wounds and non‑healing ulcers is considered investigational and is not covered. The policy explicitly lists autologous blood‑derived preparations (PRP) as investigational for acute or chronic wounds including surgical wounds and non‑healing ulcers and therefore denies coverage for these indications.

Platelet‑rich plasma (PRP) is considered investigational for the treatment of acute or chronic wounds. Systematic reviews and meta‑analyses of small controlled trials show mixed results, methodological limitations, and imprecision across outcomes such that the evidence is insufficient to conclude PRP improves net health outcomes for acute surgical, traumatic, or chronic wound care.

Specifically for chronic wounds, PRP trials and pooled analyses demonstrate heterogeneous results with moderate‑to‑high risk of bias and imprecision; while some meta‑analyses report improvements in wound closure or wound size for selected subgroups, the overall body of high‑quality evidence is insufficient to establish effectiveness, and PRP is therefore considered investigational for chronic wound indications.

The policy references Centers for Medicare & Medicaid Services materials on autologous blood‑derived products: CMS decision memos and National Coverage Analyses (e.g., the Decision Memo for Autologous Blood Derived Products for Chronic Non‑Healing Wounds, CAG‑00190R2 and the NCA tracking sheet CAG‑00190R4). Providers should align requests for autologous blood‑derived therapies with applicable CMS determinations when applicable.

This excerpt does not contain the full, explicit coverage criteria text for every indication; parts of the policy in the full document include detailed criteria, diagnosis code lists, and references supporting decisions. The available sections list covered indications for recombinant PDGF (becaplermin), investigational status for PRP, numerous ICD‑10 diagnosis codes for pressure and non‑pressure chronic ulcers, and a bibliography of trials and reviews. For definitive, itemized coverage rules and any exclusions or prior‑authorization requirements, refer to the complete policy (MP 2.033) where the formal policy statements and criteria are presented.

Coding — Procedure and Diagnosis Codes

Covered HCPCS / Procedure Codes for recombinant PDGFHCPCSCovered

S0157	Recombinant platelet-derived growth factor (per policy listing)
S9055	Recombinant platelet-derived growth factor (per policy listing)

PRP — investigational / not covered (procedure codes not enumerated)HCPCSNot Covered

No codes listed

Diagnosis codes cited for coverage (excerpt)ICD-10

E10.621	Type 1 diabetes mellitus with foot ulcer
E10.622	Type 1 diabetes mellitus with other skin ulcer
E11.621	Type 2 diabetes mellitus with foot ulcer
E11.622	Type 2 diabetes mellitus with other skin ulcer
L89.000	Pressure ulcer of unspecified elbow, unstageable
L89.001	Pressure ulcer of unspecified elbow, stage 1
L89.002	Pressure ulcer of unspecified elbow, stage 2
L89.003	Pressure ulcer of unspecified elbow, stage 3
L89.004	Pressure ulcer of unspecified elbow, stage 4
L89.006	Pressure ulcer of unspecified elbow, stage 4

Listed ICD-10 Diagnosis Codes (Pressure and Non-pressure Chronic Ulcers)ICD-10

L89.312	Pressure ulcer of unspecified hip, stage 1 = Pressure ulcer of right buttock, stage 2
L89.313	Pressure ulcer of unspecified hip, stage 1 = Pressure ulcer of right buttock, stage 3
L89.314	Pressure ulcer of unspecified hip, stage 1 = Pressure ulcer of right buttock, stage 4
L89.316	Pressure-induced deep tissue damage of right buttock
L89.319	Pressure ulcer of right buttock, unspecified stage
L89.320	Pressure ulcer of left buttock, unstageable
L89.321	Pressure ulcer of left buttock, stage 1
L89.322	Pressure ulcer of left buttock, stage 2
L89.323	Pressure ulcer of left buttock, stage 3
L89.324	Pressure ulcer of left buttock, stage 4

1–10 of 84

1/9

ICD-10-CM Diagnosis Codes — Non-pressure chronic ulcers (listed)ICD-10

L97.928	Non-pressure chronic ulcer of unspecified part of left lower leg with other specified severity
L98.411	Non-pressure chronic ulcer of buttock limited to breakdown of skin
L98.412	Non-pressure chronic ulcer of buttock with fat layer exposed
L98.413	Non-pressure chronic ulcer of buttock with necrosis of muscle
L98.414	Non-pressure chronic ulcer of buttock with necrosis of bone
L98.421	Non-pressure chronic ulcer of back limited to breakdown of skin
L98.422	Non-pressure chronic ulcer of back with fat layer exposed
L98.423	Non-pressure chronic ulcer of back with necrosis of muscle
L98.424	Non-pressure chronic ulcer of back with necrosis of bone
L98.431	Non-pressure chronic ulcer of abdomen limited to breakdown of skin

1–10 of 46

1/5

Noted coding updatesHCPCS

G0465

Added to coding in administrative update (no description in excerpt)

Transcutaneous partial pressure of oxygen (TcPO2) threshold for becaplermin candidates

TcPO2 thresholdTranscutaneous partial pressure of oxygen >= 30 mm Hg measured on the foot dorsum or at the margin of the ulcer

Ulcer stage requirementFull-thickness ulcer (Stage III or IV) extending through dermis into subcutaneous tissues

Wound-management participationParticipation in a wound-management program including sharp debridement, pressure relief/non-weight bearing, and infection control

Albumin concentration requirement (documented threshold)

Albumin concentration requirementSerum albumin concentration > 2.5 dL

Provider Actions — Prior Authorization, Documentation, and Billing

Prior Authorization

Prior authorization — document frequency, duration, and quantity

If prior authorization is required, document the planned frequency and duration of becaplermin therapy (typical regimen: once daily for up to 20 weeks) and estimated quantity (tube sizes and expected usage).

Typical treatment: once daily for up to 20 weeks or until healed
Document estimated number/size of tubes (2-, 7.5-, 15-g) based on ulcer size and expected duration

Billing Rule

Recombinant PDGF coding — S0157 and S9055

When medically necessary, recombinant platelet‑derived growth factor is billed using procedure codes S0157 and S9055; reference these codes on requests and claims for becaplermin.

Background and Evidence Summary

Platelet‑derived growth factors have been investigated to promote wound healing by delivering growth factors that stimulate cellular repair processes. Two principal approaches discussed in the policy are topical recombinant PDGF (becaplermin/Regranex) and autologous platelet‑rich plasma (PRP). Becaplermin is an FDA‑approved topical recombinant PDGF for certain diabetic neuropathic lower‑extremity ulcers and has been evaluated in randomized trials; PRP is an autologous platelet concentrate prepared at point of care, and preparation methods and platelet concentrations vary across systems, contributing to heterogeneity in study results.

The policy references CMS materials in its evidence discussion, including the CMS National Coverage Analysis tracking sheet and Decision Memo for autologous blood‑derived products for chronic non‑healing wounds; these documents are cited among the policy references and technology assessments informing the investigational stance on PRP.

The provided document segment primarily contains diagnostic code lists, references, and excerpts of background material; the full, explicit coverage criteria and procedural policy language are not present in this excerpt and must be consulted in the complete policy for definitive administrative or coverage rules.

Definitions

Becaplermin (Regranex) — definition and regulatory indication

DefinitionBecaplermin (Regranex) is a topical recombinant platelet-derived growth factor (PDGF-BB) gel approved by the FDA for treatment of lower-extremity diabetic neuropathic ulcers that extend into subcutaneous tissue and have adequate blood supply

Indication specificsUsed as an adjunct to standard ulcer care (sharp debridement, pressure relief, infection control)

Formulation & applicationAvailable in 2-, 7.5-, and 15-g tubes; applied in a thin continuous layer (~1/16 inch, ~1.6 mm)

Platelet-rich plasma (PRP) — definition and preparation details

DefinitionPlatelet-rich plasma (PRP) is an autologous platelet concentrate suspended in plasma prepared from centrifuged blood; activation (e.g., thrombin and calcium chloride) degranulates platelets releasing growth factors and forms a fibrin matrix for topical application

Revision History & Notes

2026-03-04consensus_reviewLatest

Editorial updates to the policy statement; intent unchanged; policy guidelines, background, rationale, references, and ICD-10 updated.

2025-06-25administrative_update

Removed Benefit Variations section and updated Disclaimer.

2025-02-12consensus_review

Policy Summary

PayerCapital Bluecross

PolicyRecombinant and Autologous Platelet-Derived Growth Factors as a Treatment of Wound Healing and Other Non‑Orthopedic Conditions

Policy CodePolicy MP 2.033

Change TypeNo material change

Effective DateJul 1, 2026

Last ReviewMar 4, 2026

Next Review Date

Key ActionDocument planned frequency and duration (typically once daily for up to 20 weeks) and estimated quantity when requesting prior authorization for becaplermin.

SourceLink

On This Page

Ulcer stage requirementFull-thickness ulcer (Stage III or IV) extending through dermis into subcutaneous tissues

Off-loading capabilityUlcer located in an anatomic location that can be off-loaded for the duration of treatment

Wound-management participationParticipation in a wound-management program (debridement, off-loading, infection control)

Total lymphocyte count threshold (documented)

Total lymphocyte count requirementTotal lymphocyte count > 1,000/μL

Additional laboratory requirementsNormal values of vitamins A and C (documented prior to treatment)

Typical treatment frequency/durationBecaplermin is typically applied once daily for up to 20 weeks or until healed (application may be performed at home)

Procedure codes: S0157, S9055

Note

Verify prior authorization and coding before submission

Verify current payer prior‑authorization and coding requirements before submitting requests or claims — coding updates (e.g., addition of G0465 in 2021) have been recorded and may affect submission.

Confirm applicable procedure codes and prior‑auth process with payer at time of submission
Be aware of administrative coding updates noted in policy history (G0465 added 12/01/2021)

Documentation Required

Use becaplermin only as adjunct to standard wound care

Becaplermin must be used as an adjunct to standard wound care; documentation should show concurrent or prior implementation of sharp debridement, pressure relief/non‑weight bearing (off‑loading), and infection control measures.

Participation in a wound‑management program including sharp debridement
Pressure relief/off‑loading (non‑weight bearing) for duration of treatment
Active infection control when indicated

Documentation Required

Document candidate meets becaplermin criteria (oxygenation & staging)

Include documentation that the patient meets all becaplermin candidate criteria — e.g., transcutaneous PO2 ≥ 30 mm Hg at the foot dorsum or ulcer margin and full‑thickness (Stage III/IV) ulcer extending into subcutaneous tissue — when requesting coverage.

TcPO2 ≥ 30 mm Hg measured on foot dorsum or at ulcer margin
Ulcer staged as full‑thickness (Stage III or IV) extending into subcutaneous tissue

Documentation Required

Document medical necessity and cite S0157/S9055

For recombinant PDGF requests, document medical necessity and reference the applicable procedure codes (S0157, S9055) and relevant diagnosis codes listed in the policy to support coverage.

Include procedure code(s): S0157, S9055
Cite appropriate ICD‑10 diagnosis code(s) for diabetic foot ulcer or pressure ulcer as listed in policy

Denial Risk

Avoid non‑indicated uses of recombinant PDGF — denial risk

Do not use recombinant PDGF (becaplermin) for indications outside those specified in the policy (i.e., other than neuropathic diabetic lower‑extremity ulcers extending into subcutaneous tissue or pressure ulcers extending into subcutaneous tissue); such uses are investigational and may be denied.

Investigational for ischemic ulcers, venous stasis ulcers, and ulcers not extending into subcutaneous tissue

Denial Risk

PRP for acute or chronic wounds — investigational (expect denial)

Autologous platelet‑rich plasma (PRP) for acute or chronic wounds, including surgical wounds and non‑healing ulcers, is considered investigational; anticipate a denial risk if requested for these indications.

PRP is investigational for acute surgical/traumatic wounds and chronic wounds (including surgical wounds and non‑healing ulcers)

Denial Risk

PRP for surgical wounds/non‑healing ulcers — not covered

Use of autologous blood‑derived preparations (PRP) for treatment of surgical wounds and non‑healing ulcers is explicitly considered investigational and not covered; include this in preauthorization discussions to avoid claim denials.

Policy statement: PRP for surgical wounds and non‑healing ulcers is investigational and not covered

Note

Consider CMS national coverage decisions for autologous blood‑derived products

Be aware that CMS national coverage decisions and analyses for autologous blood‑derived products (e.g., PRP) may affect coverage determinations; align requests and documentation with any relevant CMS decisions.

CMS documents cited: NCA and Decision Memos relevant to autologous blood‑derived products

Documentation Required

Provide clinical documentation supporting policy‑consistent use

Supply clinical documentation demonstrating that use is consistent with policy criteria (diagnosis, wound stage, oxygenation, participation in wound‑management program) when submitting prior authorization or claim support.

Attach wound‑management program notes, objective measurements (TcPO2), and staging
Include relevant diagnosis and procedure codes

Prior Authorization

No explicit prior‑auth requirement stated in excerpt — verify with payer

The policy guidance excerpt does not state explicit prior authorization requirements for platelet‑derived growth factor products; check payer procedures for local prior‑auth rules.

No explicit prior authorization language present in this excerpt

Prior Authorization

No explicit prior‑auth language in these chunks — confirm current requirements

Within the provided document segments there are no explicit prior authorization requirements stated for these products; do not assume authorization is not required — confirm with the payer.

Policy chunks reviewed contain no explicit prior‑auth mandates

Preparation variability

Numerous point-of-care preparation systems exist; device/method differences produce variable platelet and growth factor concentrations

Uses describedPrepared PRP/platelet gel may be applied topically to wounds or used as an adjunct in surgical procedures to promote hemostasis and healing

Diabetic neuropathic ulcer — definition

DefinitionA diabetic neuropathic ulcer is a lesion of the skin or mucous membranes caused by damage to autonomic motor and/or sensory nerves from longstanding diabetes mellitus, characterized by inflammation, necrosis, and sloughing of tissue

Clinical relevanceBecaplermin indication specifically applies to lower-extremity diabetic neuropathic ulcers that extend into subcutaneous tissue and have adequate blood supply

Policy noteRegranex efficacy not established for diabetic ulcers that do not extend into subcutaneous tissue or for ischemic diabetic ulcers

Stage III ulcer — definition

DefinitionStage III ulcer: full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia

Relevance to coverageBecaplermin candidates must have full-thickness (Stage III or IV) ulcers extending into subcutaneous tissue

Depth descriptionExtends through dermis into subcutaneous tissues

Stage IV ulcer — definition

DefinitionStage IV ulcer: full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supportive structures

Relevance to coverageBecaplermin candidates must have full-thickness (Stage III or IV) ulcers extending into subcutaneous tissue

Severity noteMay involve damage to muscle, bone, or supportive structures

Becaplermin / recombinant human PDGF-BB — referenced therapy definition

DefinitionBecaplermin is recombinant human platelet-derived growth factor (PDGF-BB) formulated as a topical gel to promote healing of diabetic neuropathic lower-extremity ulcers

MechanismDelivers PDGF-BB to stimulate cellular processes involved in wound repair

Evidence baseEvaluated in randomized trials showing improved healing for diabetic neuropathic ulcers and limited RCT data for pressure ulcers

Autologous platelet-rich plasma / platelet gel (PRP) — definition

DefinitionAutologous platelet-rich plasma (platelet gel) is prepared at point of care by activating a patient’s centrifuged platelet concentrate (e.g., with thrombin and calcium chloride) to release growth factors and create a fibrin matrix for topical application

ApplicationsUsed topically on chronic wounds or as an adjunct in surgical procedures to promote hemostasis and healing

Regulatory notePRP devices have been cleared via 510(k); PRP blood products fall under FDA tissue regulations and methods vary, contributing to heterogeneity in studies

Autologous PRP/platelet-rich gel — definition and use

Definition & useAutologous PRP/platelet-rich gel are biologic therapies prepared from a patient’s own platelets used topically or injected to potentially promote tissue regeneration and wound healing

Evidence summaryMultiple systematic reviews and meta-analyses have assessed PRP for chronic wounds with mixed results and variable study quality

Clinical implicationHeterogeneity of preparation methods and outcomes contributes to policy determination of investigational status for many wound types

Autologous blood-derived products — CMS-related definition/category

Definition/categoryAutologous blood-derived products is a CMS-referenced category encompassing PRP and related autologous blood concentrates considered in national coverage analyses for chronic non-healing wounds

Policy interactionCMS NCA/NCD documents and decision memos for autologous blood-derived products are cited and may affect coverage determinations

ExamplesIncludes PRP and platelet gels evaluated in technology assessments and CMS analyses

Pressure ulcer and non-pressure chronic ulcer ICD-10 codes — definition / code series reference

ICD-10 code series referencedPressure ulcer codes (L89.x) and non-pressure chronic ulcer codes (L97.x, L98.x) series are enumerated in the policy

UsageCodes specify anatomical sites and stages/severity of pressure and non-pressure chronic ulcers to support documentation of covered diagnoses

ExamplesSelected codes include L89.312, L89.324, L97.121, L98.411 (policy lists many specific codes)

Moved criteria into policy guidelines; policy intent unchanged; references updated and coding reviewed with no changes.

2024-02-06consensus_review

Consensus review with references updated; coding reviewed with no changes to policy statement.

2023-01-18consensus_review

Consensus review; no changes to policy statements; coding and references reviewed and updated.

2022-03-09minor_review

Minor review: criteria moved from policy guidelines to policy statement; FEP, rationale, and references updated.

2021-12-01administrative_update

Administrative update adding HCPCS code G0465 effective 01/01/2022.

2021-05-17consensus_review

Consensus review with coding and references reviewed and updated; no change to policy statements.

2020-05-15consensus_review

Consensus review; policy statement unchanged; variation, background, rationale, references, and coding updated.