1.0 CPT PROCEDURE
CODES
10021, 10022, 10040 - 11977, 11980 - 11983,
12001 - 15366, 15400 - 15431, 15570 - 15776, 15840 - 15845, 15851
- 19499, 97601, and 97602
2.0 HCPCS PROCEDURE
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) procedure code 11980, HCPCS 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.