AMERX has previously shared multiple proposals that pose a significant threat to skin substitute services. Three Part B Medicare Administrative Contractors have proposed to limit the number of skin substitute applications within an episode of care. Furthermore, CMS has proposed to bundle the payments for skin substitute application and skin substitute products in the office setting, treating the skin substitute as “incident to” the application
New United Healthcare (UHC) Policy for Skin Substitutes
Now UHC, one of the largest non–Medicare medical insurance companies in the country, has released a new skin substitute policy, effective May 1, 2023. This policy lists only EpiFix, GrafixPL, GrafixPRIME and GrafixPL PRIME (Non-Injectable) as medically necessary for treating diabetic foot ulcers when certain criteria are met. This policy also lists, by brand name, over 150 other skin substitute products that are never covered by UHC for any indication. The policy includes over 50 pages of literature review. The full policy and full list of over 150 products not covered by UHC is here:
The Four Week Requirement for Skin Substitutes
This UHC policy also states one of the criteria for coverage of skin substitute use for diabetic foot ulcers is that the “ulcer has failed to demonstrate measurable signs of healing with at least 4 weeks of standard wound care.” The policy states that standard wound care must include:
- Application of dressings to maintain a moist wound environment
- Debridement of necrotic tissue, if present
- Offloading
HELIX3® Bioactive Collagen may also be used during this 4-week period of standard wound care. This collagen attracts fibroblasts to a wound site and supports new blood vessel formation, granulation tissue formation, and epithelialization.
What is an Alternative for Skin Substitutes?
With decreasing coverage of skin substitute services and other threats to skin substitute services, dispensing collagen is an attractive option both while fulfilling the requirement of four weeks of standard wound care prior to skin substitute use and as an alternative to skin substitute use. Those who dispense collagen also enjoy the profits associated with the surgical dressing program.
Dr. Jeffrey D. Lehrman, DPM, FASPS, MAPWCA, CPC, CPMA
Dr. Lehrman is a podiatrist practicing in Fort Collins, CO and operates Lehrman Consulting, LLC which provides consultation services regarding coding, compliance and documentation. Dr. Lehrman is a Certified Professional Coder and Certified Professional Medical Auditor. He serves as a staff liaison at the AMA CPT® Editorial Panel meetings where CPT codes are created, edited, and deleted. He is a Diplomate of the American Board of Foot and Ankle Surgery, Fellow of the American Society of Podiatric Surgeons, and is recognized as a “Master” by the American Professional Wound Care Association. Dr Lehrman is a Fellow of the American Academy of Podiatric Practice Management, Past Director of the American Professional Wound Care Association Board of Directors, and is a Past Chairman of the Board of the American Society of Podiatric Surgeons. Dr. Lehrman is also on the editorial advisory board of the journal WOUNDS.
