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    v1.0.30
    OpenPayerPolicy UpdatesClinical/Medical PolicyDHA Integumentary Surgery Coverage Update | OpenPa…
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    ModifiedDHAPolicy N/A

    Integumentary System Surgery

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    This policy addresses surgical services involving the integumentary system under the DHA Policy Manual for TRICARE providers.

    Policy Summary
    PayerDHA
    PolicyIntegumentary System Surgery
    Policy CodePolicy N/A
    Change TypeModified
    Effective DateNov 9, 2007
    Next Review DateN/A
    Key ActionDo not cover topical oxygen therapy using devices that apply oxygen directly to the skin; oxygen-emitting bandages and dressings are not included in this exclusion.
    SourceLink
    POLICY UPDATE CHANGES

    Revision 30 modified exclusion 5.4 on August 15, 2018.

    Revision 30 added an exclusion for topical oxygen therapy using topical oxygen devices, continuous oxygen devices, topical oxygen hyperbaric chambers, or similar devices that apply oxygen directly to the skin.

    4Covered integumentary treatment categories or services
    3Express exclusions or noncovered service categories
    1Services requiring separate criteria under Section 5.8
    3Coverage categories with specified effective dates

    Covered Services and Exclusions

    Diagnosis and treatment of integumentary illness or injury

    Covered services.

    Integumentary illness or injury treatment: Services and supplies required in the diagnosis and treatment of illness or injury involving the integumentary system are covered.

    Specified topical and ulcer treatments

    The following treatments are covered without additional criteria stated in this section.

    Venous-insufficiency ulcer treatment: Topical application of Alpigraf by a physician for treatment of skin ulcers caused by venous insufficiency is a covered benefit.
    Diabetic foot ulcer tissue-cultured graft: Application of tissue cultured skin grafts for diabetic foot ulcers is a covered benefit.
    Policy Summary
    PayerDHA
    PolicyIntegumentary System Surgery
    Policy CodePolicy N/A
    Change TypeModified
    Effective DateNov 9, 2007
    Next Review DateN/A
    Key ActionDo not cover topical oxygen therapy using devices that apply oxygen directly to the skin; oxygen-emitting bandages and dressings are not included in this exclusion.
    SourceLink
    On This Page
    Covered Services and ExclusionsProcedure CodesExclusions and Billing AlertsIntegumentary System OverviewKey Terms

    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.

    Diabetic neuropathic foot ulcer Becaplermin treatment: Application of Becaplermin Gel (Regranex) is covered for lower extremity diabetic neuropathic foot ulcers that extend into the subcutaneous tissue or beyond.Ulcer extends into the subcutaneous tissue or beyond

    Negative Pressure Wound Therapy

    May be covered when the applicable criteria in Section 5.8 are met.

    Negative pressure wound therapy may be covered when certain criteria are met.

    See Section 5.8 for the applicable criteria.

    Testopel pellet coverage

    Covered for one of the following FDA label indications.

    Testopel for adult male hypogonadism: Testopel pellets are covered as second-line testosterone replacement therapy in males with congenital or acquired endogenous androgen absence or deficiency associated with primary or secondary hypogonadism when intramuscular or transdermal testosterone replacement therapy is ineffective or inappropriate.Intramuscular or transdermal testosterone replacement therapy is ineffective or inappropriate

    Must be an FDA label indication.

    Testopel for delayed male puberty: Testopel pellets are covered for treatment of delayed male puberty.

    Must be an FDA label indication.

    Routine podiatry services, including removal of corns or calluses, trimming of toenails, and other routine podiatry care, are excluded unless required because of a diagnosed systemic medical disease affecting the lower limbs, such as severe diabetes.

    Services performed for cosmetic purposes are excluded from coverage.

    Custom-compounded subcutaneous implantable pellets for female hormone replacement therapy containing estradiol, estrogen, or testosterone in combination with estrogen or estradiol are not covered because the pellets are not FDA approved.

    Topical oxygen therapy using topical oxygen devices, continuous oxygen devices, topical oxygen hyperbaric chambers, or similar devices that apply oxygen directly to the skin is unproven and excluded. This exclusion does not include medical supplies such as oxygen-emitting bandages and dressings.

    Procedure Codes

    CPT Procedure CodesCPT
    10021
    10022
    10040 - 11977
    11980 - 11983
    12001 - 15366
    15400 - 15431
    15570 - 15776
    15840 - 15845
    15851 - 19499
    97601
    1–10 of 11
    1/2
    HCPCS Procedure CodeHCPCS
    S0189
    Not Covered Hormone Replacement Therapy CodesmixedNot Covered
    11980Subcutaneous implantable pellets (Current Procedural Terminology (CPT) procedure code 11980) for Hormone Replacement Therapy (HRT) in females that are made up of estradiol, estrogen, or testosterone in combination with estrogen or estradiol have been custom-compounded by pharmacists are not covered, as these pellets are not approved by the FDA.
    J3490Subcutaneous implantable pellets (HCPCS J3490) for Hormone Replacement Therapy (HRT) in females that are made up of estradiol, estrogen, or testosterone in combination with estrogen or estradiol have been custom-compounded by pharmacists are not covered, as these pellets are not approved by the FDA.
    S0189Subcutaneous implantable pellets (HCPCS S0189) for Hormone Replacement Therapy (HRT) in females that are made up of estradiol, estrogen, or testosterone in combination with estrogen or estradiol have been custom-compounded by pharmacists are not covered, as these pellets are not approved by the FDA.

    Exclusions and Billing Alerts

    Denial Risk

    Custom-compounded female HRT pellets are not covered

    Do not expect coverage for female hormone replacement therapy using custom-compounded subcutaneous implantable pellets containing estradiol, estrogen, or testosterone in combination with estrogen or estradiol. These pellets are not covered because they are not FDA approved.

    • Applies to CPT 11980, HCPCS J3490, and HCPCS S0189.
    • The pellets must have been custom-compounded by pharmacists.
    Denial Risk

    Cosmetic services are excluded

    Services performed for cosmetic purposes are excluded and may be denied as noncovered services. Confirm that the service is intended to diagnose or treat illness or injury rather than for cosmetic purposes.

    Documentation Required

    Document the medical exception for routine podiatry

    Routine podiatry services are excluded, including removal of corns or calluses, trimming of toenails, and other routine services. Coverage applies only when the service is required as a result of diagnosed systemic medical disease affecting the lower limbs, such as severe diabetes.

    • Document the diagnosed systemic medical disease affecting the lower limbs when it is the basis for the service.
    • Severe diabetes is an example stated in the policy.
    Denial Risk

    Topical oxygen devices and therapies are excluded

    Topical oxygen therapy using topical oxygen devices, continuous oxygen devices, topical oxygen hyperbaric chambers, or similar devices that apply oxygen directly to the skin is unproven and excluded. Oxygen-emitting bandages and dressings are not included in this exclusion.

    • Do not submit the excluded topical oxygen devices or therapies as covered services.
    • Oxygen-emitting bandages and dressings are expressly excluded from this exclusion.

    Integumentary System Overview

    The integumentary system includes the skin, subcutaneous tissue, and areolar tissue, together with accessory structures such as the lips and nails. The policy addresses treatment of illness or injury involving these structures, including venous-insufficiency ulcers, diabetic foot ulcers, wound therapy, and certain testosterone pellet indications.

    Key Terms

    Integumentary System
    SkinIncluded in the integumentary system.
    Subcutaneous tissueIncluded in the integumentary system.
    Areolar tissueIncluded in the integumentary system.
    Accessory structuresIncludes the lips and nails, among other accessory structures of the skin.
    Negative Pressure Wound Therapy
    Coverage statusNegative pressure wound therapy may be covered.
    Applicable criteriaCoverage requires satisfaction of certain criteria.
    Related sectionSee Section 5.8 for the applicable criteria.