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.