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TRICARE Policy Manual 6010.63-M, April 2021
Surgery
Chapter 4
Section 5.1
Integumentary System
Issue Date:  August 26, 1985
Authority:  32 CFR 199.4(c)(2) and (c)(3)
Copyright:  CPT only © 2006 American Medical Association (or such other date of publication of CPT). All Rights Reserved.
Revision:  
1.0  CPT CODES
10021, 10022, 10040 - 11977, 11980 - 11983, 12001 - 15366, 15400 - 15431, 15570 - 15776, 15840 - 15845, 15851 - 19499, 97601, and 97602
2.0  HCPCS CODE
S0189
3.0  DESCRIPTION
Integumentary system pertains to the skin, subcutaneous tissue and areolar tissue and other accessory structures of the skin such as the lips, nails, etc.
4.0  POLICY
4.1  Services and supplies required in the diagnosis and treatment of illness or injury involving the integumentary system are covered.
4.2  Topical Treatment of Skin Ulcers Caused by Venous Insufficiency. Topical application of Alpigraf by a physician for the treatment of skin ulcers caused by venous insufficiency is a covered benefit.
4.3  Topical Treatment of Diabetic Foot Ulcers.
4.3.1  Application of tissue cultured skin grafts for diabetic foot ulcers is a covered benefit.
4.3.2  Application of Becaplermine Gel (Regranex) is a covered treatment of lower extremity diabetic neuropathic foot ulcers that extend into the subcutaneous tissue or beyond.
4.4  Negative Pressure Wound Therapy (NPWT) may be covered when certain criteria are met. See Section 5.8.
4.5  Testopel pellets (testosterone pellets) are covered for one of the following U. S. Food and Drug Administration (FDA) label indications:
4.5.1  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; or
4.5.2  For treatment of delayed male puberty.
5.0  EXCLUSIONS
5.1  Removal of corns or calluses or trimming of toenails and other routine podiatry services, except those required as a result of diagnosed systemic medical disease affecting the lower limbs, such as severe diabetes.
5.2  Services performed for cosmetic purposes.
5.3  Subcutaneous implantable pellets (Current Procedural Terminology (CPT) code 11980, Healthcare Common Procedure Coding System (HCPCS) codes J3490 and 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.
5.4  Topical oxygen therapy using topical oxygen devices, continuous oxygen devices, topical oxygen hyperbaric chambers, or similar devices that apply oxygen directly to the skin (but not including medical supplies such as oxygen emitting bandages and dressings) is unproven.
6.0  EFFECTIVE DATES
6.1  Effective May 26, 1998, for topical treatment of skin ulcers caused by venous insufficiency.
6.2  Effective May 8, 2000, for topical treatment of diabetic foot ulcers.
6.3  Effective December 16, 1997, for topical treatment of diabetic foot ulcers application of Becaplermine Gel (Regranex).
6.4  Effective November 9, 2007, for NPWT.
- END -

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