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