Skin and Soft Tissue Substitutes
Medical necessity criteria and coverage policy for use of skin and soft tissue substitutes/cellular and tissue-based products (CTPs) for chronic wounds, burns, breast reconstruction, abdominal wall reconstruction, and specific inherited conditions; applies to non‑Medicare health plans affiliated with Centene Corporation.
Changed requirement for no nicotine use for at least 4 weeks to documentation of effort to cease nicotine use, or no nicotine use for at least 4 weeks.
In diabetic foot ulcer criteria, removed requirement of neuropathy and changed HbA1c threshold from ≤7% to ≤8%, or allow if documented improvement in last 4 weeks; HbA1c >8% or no documented improvement is a contraindication.
Changed contraindication language from 'active Charcot arthropathy of the ulcer extremity' to 'active Charcot arthropathy of the ulcer surface.'
Removed requirement for MD review of all requests and removed detailed documentation requirements (physical activity, nutrition, prosthetic check, diabetes management history) for DFU.
Changed HbA1c requirement from ≤7% to ≤8%, or allow ≤8% with documented improvement of blood glucose in last 4 weeks; contraindication changed to >8% or with no documented improvement in last 4 weeks.
Added numerous HCPCS codes to tables and reorganized codes into tables that support medical necessity vs do not support medical necessity; added HCPCS Table 1 and Table 2/3 changes.
Expanded policy to include full thickness skin-loss ulcers and soft tissue substitutes for additional indications (burns, breast reconstruction, dystrophic epidermolysis bullosa, post-reconstructive abdominal wall wounds).
Specified that medical necessity criteria apply to up to four initial applications and created separate criteria for up to a total of eight applications.
Changed smoking criterion to require documentation of effort to cease nicotine use, or no nicotine use for at least 4 weeks (previously required no nicotine use for 4 weeks).
Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.