Aetna Wound Care (Skin and Soft Tissue Substitutes) coverage criteria

What this means for the claim

The covered path, the next step to get it approved, and the specific way it denies — built only from this policy.

Coverage criteria

• General chronic-wound coverage — skin/soft tissue substitutes are medically necessary for chronic wounds that failed to respond to treatment when ALL of the following are met: (1) member is 18 years or older; (2) non-smoker OR has completed or is enrolled in smoking cessation therapy; (3) wound characteristics documented with photo and ruler showing a partial- or full-thickness skin defect >=1 cm^2, clean, free of necrotic debris; (4) wound has increased in size/depth OR is unchanged from baseline with no improvement indicators (granulation, epithelialization, progress toward closure) after >=4 weeks of standard wound care (debridement, dressings, elimination of contributing factors); (5) no tendon, muscle, joint capsule, exposed bone, or sinus tract involvement; (6) no wound infection, cellulitis, osteomyelitis, foreign body, or malignant process; (7) all underlying conditions/factors preventing healing have been eliminated
• AlloDerm and AlloDerm-RTU acellular dermal tissue matrix — medically necessary for ANY of: breast reconstructive surgery; partial glossectomy for tongue cancer; complex abdominal wall wound repair (infection, fascial defect); ear drum augmentation (tympanoplasty), skull base defect repair, or temporal bone lining; nasal septal perforation <2 cm in greatest dimension that has failed conservative treatment; nasal reconstruction without cartilage / thin mucosal flaps to prevent perforation
• Allogeneic human, cadaver-derived skin graft — medically necessary for traumatic skin wounds and burn wounds too large for autograft
• AlloPatch — medically necessary for partial- or full-thickness neuropathic diabetic foot ulcers >6 weeks duration, with no capsule/tendon/bone exposed, used with standard diabetic care
• AlloSkin — medically necessary for traumatic skin wounds and burn wounds too large for autograft (NOTE: applies to AlloSkin only, NOT AlloSkin AC or AlloSkin RT)
• AmnioBand — medically necessary for EITHER: difficult-to-heal chronic venous partial- or full-thickness lower extremity ulcers that failed standard therapy >=4 weeks; OR partial-/full-thickness neuropathic diabetic foot ulcers >6 weeks, no capsule/tendon/bone exposed, with standard care
• Apligraf (graftskin) — medically necessary for EITHER: full-thickness neuropathic diabetic foot ulcers >4 weeks not adequately responsive to conventional therapy, extending through the dermis without tendon/muscle/capsule/bone exposure; OR chronic non-infected partial-/full-thickness venous stasis ulcers >4 weeks that failed conservative measures (regular dressing changes, compression), used with standard therapy
• Artiss fibrin sealant — medically necessary for treatment of severe burns
• Biobrane Biosynthetic Dressing — medically necessary as temporary covering of superficial partial-thickness burn wounds
• DermACELL — medically necessary for EITHER: partial-/full-thickness neuropathic diabetic foot ulcers >6 weeks, no capsule/tendon/bone exposed, with standard care; OR oro-nasal fistula following cleft palate repair
• Dermagraft — medically necessary for EITHER: full-thickness diabetic foot ulcers >4 weeks extending through the dermis without tendon/muscle/joint capsule/bone exposure; OR wounds related to dystrophic epidermolysis bullosa (used with standard wound care; contraindicated in infected ulcers and ulcers with sinus tracts)
• Epicel cultured epidermal autograft — medically necessary for deep dermal or full-thickness burns comprising >=30% total body surface area
• Epicord — medically necessary for partial-/full-thickness neuropathic diabetic foot ulcers >4 weeks, no capsule/tendon/bone exposed, with standard care
• EpiFix — medically necessary for EITHER: partial-/full-thickness neuropathic diabetic foot ulcers >4 weeks, no capsule/tendon/bone exposed, with standard care; OR difficult-to-heal chronic venous or diabetic partial-/full-thickness lower extremity ulcers that failed standard therapy >=4 weeks
• Grafix (Grafix Core and Grafix Prime) — medically necessary for partial-/full-thickness neuropathic diabetic foot ulcers >4 weeks, no capsule/tendon/bone exposed, with standard care
• Graftjacket Regenerative Tissue Matrix — medically necessary for EITHER: full-thickness diabetic foot ulcers >4 weeks extending through the dermis without tendon/muscle/joint capsule/bone exposure; OR oro-nasal fistula following cleft palate repair
• Integra Dermal Regeneration Template and Integra Bilayer Wound Matrix — medically necessary for EITHER: severe burns with limited autograft skin availability or patients too ill for additional wound sites; OR partial-/full-thickness neuropathic diabetic foot ulcers >6 weeks, no capsule/tendon/bone exposed, with standard care (Integra DRT and Omnigraft versions)
• Oasis Wound Matrix — medically necessary for EITHER: partial-/full-thickness neuropathic diabetic foot ulcers >4 weeks, no capsule/tendon/bone exposed, with standard care; OR difficult-to-heal chronic venous partial-/full-thickness lower extremity ulcers that failed standard therapy >=4 weeks
• Orcel (bilayered cellular matrix) — medically necessary for EITHER: healing donor site wounds in burn victims; OR persons with dystrophic epidermolysis bullosa undergoing hand reconstruction surgery
• Strattice Reconstructive Tissue Matrix — medically necessary for complex abdominal wall wound surgical repair (infection, fascial defect)
• TheraSkin — medically necessary for EITHER: partial-/full-thickness neuropathic diabetic foot ulcers >4 weeks, no capsule/tendon/bone exposed, with standard care; OR as an allogeneic cadaver-derived skin graft for traumatic/burn wounds too large for autograft
• TransCyte (allogeneic human dermal fibroblasts) — medically necessary for EITHER: temporary wound covering for surgically excised full-thickness/deep partial-thickness thermal burns before autograft; OR mid-dermal to indeterminate depth burn wounds expected to heal without autografting
• Diabetic foot ulcer (DFU) additional criteria — when any covered product is used for a DFU (>=1 cm^2), ALL of the following must ALSO be met: hemoglobin A1c <=8% OR documentation of improving control; wound increased or unchanged after >=4 weeks of standard care (debridement, dressings, compression, off-loading) with no improvement indicators; no osteomyelitis or infection nidus; adequate circulation by exam/imaging (palpable dorsalis pedis or posterior tibial pulse; OR ankle-brachial index 0.7-1.2 without calcification, or evidence of non-fully-calcified vessels via triphasic/biphasic Doppler at the ankle of the affected leg); applied with conservative therapy (moist wound environment with dressings, non-weight bearing, pressure reduction)
• Venous leg ulcer (VLU) additional criteria — when products are used for a VLU (>=1 cm^2), ALL of the following must be met: wound increased or unchanged after >=4 weeks of standard care (debridement, dressings, compression, off-loading) with no improvement indicators; adequate circulation by exam/imaging (palpable pulse or ABI >=0.7); application with conservative therapy (e.g., compression wraps)
• Burn wound additional criteria — for partial-/full-thickness burn wounds, ALL of the following must be met: sufficient full-thickness autograft unavailable at time of excision OR not feasible due to member's physiological condition; no evidence of burn wound infection; burn wound excision complete (nonviable tissue removed) and homeostasis achieved
• Continuation of therapy — treatment continues as medically necessary when ALL of the following are met: duration no more than 12 weeks; applications comply with FDA guidelines and do not exceed 10 applications/treatments per 12-week period (EpiFix limited to 1 application/week for up to 12 weeks); only ONE substitute product used simultaneously per wound episode; product change allowed within the 10-application limit per wound per 12-week period (documented clinical necessity, subject to review); progressive healing demonstrated through measurable wound characteristic changes with measurements every <=14 days; photographic documentation with ruler AND evidence of wound improvement in the medical record; improvement evidenced by measurable changes in drainage, granulation tissue, inflammation, necrotic tissue/slough, pain/tenderness, swelling, tunneling/undermining, and wound dimensions (length, width, depth)

Covered codes

Codes listed in this Aetna policy. Check each one's prior-authorization verdict and Medicare rate:

• 15271·PA verdict·Rate
• 15272·PA verdict·Rate
• 15273·PA verdict·Rate
• 15274·PA verdict·Rate
• 15275·PA verdict·Rate
• 15276·PA verdict·Rate
• 15277·PA verdict·Rate
• 15278·PA verdict·Rate
• Q4101·PA verdict·Rate
• Q4106·PA verdict·Rate
• Q4110·PA verdict·Rate
• Q4116·PA verdict·Rate
• Q4122·PA verdict·Rate
• Q4128·PA verdict·Rate
• Q4130·PA verdict·Rate
• Q4131·PA verdict·Rate
• Q4132·PA verdict·Rate
• Q4133·PA verdict·Rate
• Q4186·PA verdict·Rate

Documentation required

• Attestation of non-smoker status OR completion of / enrollment in smoking cessation therapy
• Documentation of wound characteristics and treatment plan, with a photo that includes a ruler
• Photographic documentation with a ruler for continuation of therapy
• Evidence in the member's medical record of wound improvement
• Wound measurements taken at intervals of no more than every 14 days to demonstrate progressive healing
• Medical records, test results, and provider credentials as part of coverage determination, quality improvement, and fraud/waste/abuse prevention processes

Frequently asked questions

When does Aetna cover Wound Care (Skin and Soft Tissue Substitutes) (CPT 15271), and what gets it denied?

Aetna covers skin and soft tissue substitutes for chronic wounds (chiefly diabetic foot ulcers, venous leg ulcers, and burns) that remain unhealed after at least 4 weeks of standard wound care, only when product-specific and general gates are met: member age 18+, non-smoking status, a documented clean wound >=1 cm^2 with no exposed tendon/muscle/bone/capsule and no infection, adequate circulation, and (for DFU) controlled A1c. Therapy is capped at 12 weeks and up to 10 applications with documented progressive healing; pressure ulcers, Mohs repair, treatment beyond 12 weeks, and a very large list of amniotic, collagen, and other matrix products are considered not medically necessary or experimental/investigational. The bulletin is silent on whether precertification is required. Coverage criteria include: General chronic-wound coverage — skin/soft tissue substitutes are medically necessary for chronic wounds that failed to respond to treatment when ALL of the following are met: (1) member is 18 years or older; (2) non-smoker OR has completed or is enrolled in smoking cessation therapy; (3) wound characteristics documented with photo and ruler showing a partial- or full-thickness skin defect >=1 cm^2, clean, free of necrotic debris; (4) wound has increased in size/depth OR is unchanged from baseline with no improvement indicators (granulation, epithelialization, progress toward closure) after >=4 weeks of standard wound care (debridement, dressings, elimination of contributing factors); (5) no tendon, muscle, joint capsule, exposed bone, or sinus tract involvement; (6) no wound infection, cellulitis, osteomyelitis, foreign body, or malignant process; (7) all underlying conditions/factors preventing healing have been eliminated; AlloDerm and AlloDerm-RTU acellular dermal tissue matrix — medically necessary for ANY of: breast reconstructive surgery; partial glossectomy for tongue cancer; complex abdominal wall wound repair (infection, fascial defect); ear drum augmentation (tympanoplasty), skull base defect repair, or temporal bone lining; nasal septal perforation <2 cm in greatest dimension that has failed conservative treatment; nasal reconstruction without cartilage / thin mucosal flaps to prevent perforation; Allogeneic human, cadaver-derived skin graft — medically necessary for traumatic skin wounds and burn wounds too large for autograft; AlloPatch — medically necessary for partial- or full-thickness neuropathic diabetic foot ulcers >6 weeks duration, with no capsule/tendon/bone exposed, used with standard diabetic care; AlloSkin — medically necessary for traumatic skin wounds and burn wounds too large for autograft (NOTE: applies to AlloSkin only, NOT AlloSkin AC or AlloSkin RT); AmnioBand — medically necessary for EITHER: difficult-to-heal chronic venous partial- or full-thickness lower extremity ulcers that failed standard therapy >=4 weeks; OR partial-/full-thickness neuropathic diabetic foot ulcers >6 weeks, no capsule/tendon/bone exposed, with standard care; Apligraf (graftskin) — medically necessary for EITHER: full-thickness neuropathic diabetic foot ulcers >4 weeks not adequately responsive to conventional therapy, extending through the dermis without tendon/muscle/capsule/bone exposure; OR chronic non-infected partial-/full-thickness venous stasis ulcers >4 weeks that failed conservative measures (regular dressing changes, compression), used with standard therapy; Artiss fibrin sealant — medically necessary for treatment of severe burns; Biobrane Biosynthetic Dressing — medically necessary as temporary covering of superficial partial-thickness burn wounds; DermACELL — medically necessary for EITHER: partial-/full-thickness neuropathic diabetic foot ulcers >6 weeks, no capsule/tendon/bone exposed, with standard care; OR oro-nasal fistula following cleft palate repair; Dermagraft — medically necessary for EITHER: full-thickness diabetic foot ulcers >4 weeks extending through the dermis without tendon/muscle/joint capsule/bone exposure; OR wounds related to dystrophic epidermolysis bullosa (used with standard wound care; contraindicated in infected ulcers and ulcers with sinus tracts); Epicel cultured epidermal autograft — medically necessary for deep dermal or full-thickness burns comprising >=30% total body surface area; Epicord — medically necessary for partial-/full-thickness neuropathic diabetic foot ulcers >4 weeks, no capsule/tendon/bone exposed, with standard care; EpiFix — medically necessary for EITHER: partial-/full-thickness neuropathic diabetic foot ulcers >4 weeks, no capsule/tendon/bone exposed, with standard care; OR difficult-to-heal chronic venous or diabetic partial-/full-thickness lower extremity ulcers that failed standard therapy >=4 weeks; Grafix (Grafix Core and Grafix Prime) — medically necessary for partial-/full-thickness neuropathic diabetic foot ulcers >4 weeks, no capsule/tendon/bone exposed, with standard care; Graftjacket Regenerative Tissue Matrix — medically necessary for EITHER: full-thickness diabetic foot ulcers >4 weeks extending through the dermis without tendon/muscle/joint capsule/bone exposure; OR oro-nasal fistula following cleft palate repair; Integra Dermal Regeneration Template and Integra Bilayer Wound Matrix — medically necessary for EITHER: severe burns with limited autograft skin availability or patients too ill for additional wound sites; OR partial-/full-thickness neuropathic diabetic foot ulcers >6 weeks, no capsule/tendon/bone exposed, with standard care (Integra DRT and Omnigraft versions); Oasis Wound Matrix — medically necessary for EITHER: partial-/full-thickness neuropathic diabetic foot ulcers >4 weeks, no capsule/tendon/bone exposed, with standard care; OR difficult-to-heal chronic venous partial-/full-thickness lower extremity ulcers that failed standard therapy >=4 weeks; Orcel (bilayered cellular matrix) — medically necessary for EITHER: healing donor site wounds in burn victims; OR persons with dystrophic epidermolysis bullosa undergoing hand reconstruction surgery; Strattice Reconstructive Tissue Matrix — medically necessary for complex abdominal wall wound surgical repair (infection, fascial defect); TheraSkin — medically necessary for EITHER: partial-/full-thickness neuropathic diabetic foot ulcers >4 weeks, no capsule/tendon/bone exposed, with standard care; OR as an allogeneic cadaver-derived skin graft for traumatic/burn wounds too large for autograft; TransCyte (allogeneic human dermal fibroblasts) — medically necessary for EITHER: temporary wound covering for surgically excised full-thickness/deep partial-thickness thermal burns before autograft; OR mid-dermal to indeterminate depth burn wounds expected to heal without autografting; Diabetic foot ulcer (DFU) additional criteria — when any covered product is used for a DFU (>=1 cm^2), ALL of the following must ALSO be met: hemoglobin A1c <=8% OR documentation of improving control; wound increased or unchanged after >=4 weeks of standard care (debridement, dressings, compression, off-loading) with no improvement indicators; no osteomyelitis or infection nidus; adequate circulation by exam/imaging (palpable dorsalis pedis or posterior tibial pulse; OR ankle-brachial index 0.7-1.2 without calcification, or evidence of non-fully-calcified vessels via triphasic/biphasic Doppler at the ankle of the affected leg); applied with conservative therapy (moist wound environment with dressings, non-weight bearing, pressure reduction); Venous leg ulcer (VLU) additional criteria — when products are used for a VLU (>=1 cm^2), ALL of the following must be met: wound increased or unchanged after >=4 weeks of standard care (debridement, dressings, compression, off-loading) with no improvement indicators; adequate circulation by exam/imaging (palpable pulse or ABI >=0.7); application with conservative therapy (e.g., compression wraps); Burn wound additional criteria — for partial-/full-thickness burn wounds, ALL of the following must be met: sufficient full-thickness autograft unavailable at time of excision OR not feasible due to member's physiological condition; no evidence of burn wound infection; burn wound excision complete (nonviable tissue removed) and homeostasis achieved; Continuation of therapy — treatment continues as medically necessary when ALL of the following are met: duration no more than 12 weeks; applications comply with FDA guidelines and do not exceed 10 applications/treatments per 12-week period (EpiFix limited to 1 application/week for up to 12 weeks); only ONE substitute product used simultaneously per wound episode; product change allowed within the 10-application limit per wound per 12-week period (documented clinical necessity, subject to review); progressive healing demonstrated through measurable wound characteristic changes with measurements every <=14 days; photographic documentation with ruler AND evidence of wound improvement in the medical record; improvement evidenced by measurable changes in drainage, granulation tissue, inflammation, necrotic tissue/slough, pain/tenderness, swelling, tunneling/undermining, and wound dimensions (length, width, depth). Applies to 19 codes: 15271, 15272, 15273, 15274, 15275, 15276, 15277, 15278, Q4101, Q4106, Q4110, Q4116, Q4122, Q4128, Q4130, Q4131, Q4132, Q4133, Q4186. Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Documentation: Attestation of non-smoker status OR completion of / enrollment in smoking cessation therapy; Documentation of wound characteristics and treatment plan, with a photo that includes a ruler; Photographic documentation with a ruler for continuation of therapy; Evidence in the member's medical record of wound improvement; Wound measurements taken at intervals of no more than every 14 days to demonstrate progressive healing; Medical records, test results, and provider credentials as part of coverage determination, quality improvement, and fraud/waste/abuse prevention processes. Policy exclusions and limitations: Not medically necessary: any indications not listed in the clinical criteria section; Not medically necessary: pressure ulcer treatment; Not medically necessary: continued treatment when the ulcer fails to heal by >=50% within the first 6 weeks; Not medically necessary: treatment beyond 12 weeks regardless of wound status; Not medically necessary: continued use after treatment failure (repeat or alternative application within one year for venous stasis or diabetic foot ulcer); Not medically necessary: repair following Mohs surgery; Not medically necessary: retreatment of healed ulcers (>=75% size reduction, smaller than 1 cm^2); Experimental/investigational: MariGen for diabetic foot ulcer wounds; Not separately reimbursable: Cryolife BioGlue (considered incidental to surgery); Not separately reimbursed: Tisseel (integral to surgery); Not separately reimbursed: DuraSeal (integral to dural repair during spinal surgery); Experimental/investigational: Abiomend Membrane, Abiomend Hydromembrane, Abiomend Xplus Membrane, Abiomend Xplus Hydromembrane; Experimental/investigational: Absolv3 Membrane; Experimental/investigational: ACApatch; Experimental/investigational: Acesso, Acesso AC, Acesso DL, Acesso TL; Experimental/investigational: ACM Surgical Collagen, ACM Surgical Extra Advanced Collagen, ACM Surgical Extra Advanced Collagen Powder; Experimental/investigational: ActiGraft; Experimental/investigational: AC5 Advanced Wound System; Experimental/investigational: Activate Matrix; Experimental/investigational: Adherus Dural Sealant; Experimental/investigational: AdvoGraft Membrane Dual, AdvoGraft One; Experimental/investigational: AeroGuard; Experimental/investigational: Affinity Human Amniotic Allograft; Experimental/investigational: Alexiguard dl-t, Alexiguard sl-t, Alexiguard tl-t; Experimental/investigational: Allacor P; Experimental/investigational: AlloDerm for carotid artery protection post-radical neck dissection; Experimental/investigational: AlloGen, AlloGen Liquid; Experimental/investigational: AlloMax (non-breast indications); Experimental/investigational: alloPLY; Experimental/investigational: AlloSkin AC Acellular Dermal Matrix, AlloSkin RT; Experimental/investigational: AlloWrap; Experimental/investigational: AlphaGems amniotic tissue allograft; Experimental/investigational: AltiPlast, AltiPly; Experimental/investigational: Ambio Choice amniotic membrane; Experimental/investigational: Amchomatrix dl, Amniomatrix f4x; Experimental/investigational: AmchoPlast, AmchoPlast EXCEL, AmchoPlast FD, AmchoThick; Experimental/investigational: American Amnion, American Amnion AC, American Amnion AC Tri-Layer; Experimental/investigational: Amnioamp-mp; Experimental/investigational: AmnioArmor; Experimental/investigational: Amnio Burgeon Dual-Layer Membrane, Amnio Burgeon Membrane/Hydromembrane, Amnio Burgeon XPlus Membrane/XPlus Hydromembrane; Experimental/investigational: AmnioCare; Experimental/investigational: AmnioCord; Experimental/investigational: AmnioCore Pro, AmnioCore Pro+, AmnioCore SL; Experimental/investigational: AmnioCyte Plus; Experimental/investigational: AmnioDefend FT Matrix; Experimental/investigational: AmnioExCel; Experimental/investigational: AmnioFill Human Placental Tissue Allograft; Experimental/investigational: AmnioFix Amnion/Chorion Membrane Allograft; Experimental/investigational: Amnio FRT; Experimental/investigational: AmnioGenix; Experimental/investigational: AmnioHeal amniotic membrane; Experimental/investigational: Amniomatrix Human Amniotic Suspension Allograft, Amniomatrix f3x; Experimental/investigational: Amnio-Maxx, Amnio-Maxx Lite; Experimental/investigational: AmnioMTM; Experimental/investigational: Amnion allograft ASG; Experimental/investigational: Amnion Bio; Experimental/investigational: AmnioPlast 1, AmnioPlast 2, AmnioPlast 3; Experimental/investigational: Amnio Quad-Core; Experimental/investigational: Amniorepair; Experimental/investigational: Amnios' acellular liquid amnion; Experimental/investigational: AmnioShield; Experimental/investigational: AmnioStrip; Experimental/investigational: Amniotext (suspension/patch); Experimental/investigational: Amnio Tri-Core; Experimental/investigational: AmnioTX; Experimental/investigational: Amnio Wound; Experimental/investigational: AmnioWrap2; Experimental/investigational: Amniotic fluid injection for wound/corneal wound healing and adhesion prevention post-orthopedic surgery; Experimental/investigational: Amniox (human embryonic membrane) for tarsal tunnel repair and all other indications; Experimental/investigational: Amniply; Experimental/investigational: AmnyoFactor; Experimental/investigational: AmnyoFluid; Experimental/investigational: Apis; Experimental/investigational: Apligraf for necrotizing lesions; Experimental/investigational: Architect ECM, Architect PX; Experimental/investigational: ArdeoGraft; Experimental/investigational: Artacent C, Artacent Cord, Artacent Trident, Artacent Velos, Artacent VeriClen, Artacent Wound; Experimental/investigational: Artelon (poly[urethane urea] elastomer) for ACL reconstruction, rotator cuff repair, trapezio-metacarpal joint osteoarthritis and all other indications; Experimental/investigational: Arthres GraftRope for AC joint separation reconstruction; Experimental/investigational: Arthrex Amnion matrix, Arthrex Amnion viscous; Experimental/investigational: Arthroflex (FlexGraft); Experimental/investigational: Ascent (injectable from human amniotic fluid); Experimental/investigational: Autologous blood-derived products (PRP, platelet gel, growth factors — Autologel, Procuren, SafeBlood); Experimental/investigational: Autologous fat for scars; Experimental/investigational: Avotermin for skin scarring improvement; Experimental/investigational: AxoBioMembrane; Experimental/investigational: Axolotl Ambient, Axolotl Cryo, Axolotl DualGraft, Axolotl Graft; Experimental/investigational: Barrera SL, Barrera DL; Experimental/investigational: BellaCell HD; Experimental/investigational: BioDexcel; Experimental/investigational: BioDfactor Viable Tissue Matrix; Experimental/investigational: BioDfence human amniotic allograft, BioDfence Dryflex; Experimental/investigational: BioDmatrix; Experimental/investigational: BioDRestore Elemental Tissue Matrix; Experimental/investigational: Bio-ConneKt; Experimental/investigational: BioFix Amniotic Membrane Allograft, BioFix Flow Placental Tissue Matrix Allograft; Experimental/investigational: Bioinductive implant Regeneten; Experimental/investigational: Bionect; Experimental/investigational: BioSkin Flow; Experimental/investigational: Biostat Biologx fibrin sealant for wound healing and all other indications; Experimental/investigational: Biotape reinforcement matrix for soft tissue augmentation and all other indications; Experimental/investigational: Biovance Amniotic Membrane Allograft, Biovance Tri-layer, Biovance 3L; Experimental/investigational: BioWound Membrane, BioWound Plus Membrane, BioWound XPlus Membrane; Experimental/investigational: CaregraFT; Experimental/investigational: carePATCH; Experimental/investigational: celera Dual Membrane, celera Dual Layer; Experimental/investigational: CellECT (human amnion/amniotic fluid allograft); Experimental/investigational: CellerateRX; Experimental/investigational: Cellesta Cord, Cellesta Duo, Cellesta Flowable Amnion; Experimental/investigational: Cellgenuity amniotic fluid; Experimental/investigational: Choriofix; Experimental/investigational: Choriply; Experimental/investigational: Clarix 100, Clarix Cord 1K, Clarix Flo; Experimental/investigational: Cocoon Membrane; Experimental/investigational: Cogenex amniotic membrane, Cogenex Flowable Amnion; Experimental/investigational: CollaFix; Experimental/investigational: Colla-Pad; Experimental/investigational: CollaSorb collagen dressing; Experimental/investigational: CollaWound collagen sponge; Experimental/investigational: Coll-e-Derm; Experimental/investigational: Collexa; Experimental/investigational: Complete AA, Complete ACA, Complete FT, Complete SL; Experimental/investigational: Conexa reconstructive tissue matrix; Experimental/investigational: Cook Medical anal fistula plug; Experimental/investigational: CoreCyte, CoreText; Experimental/investigational: CorMatrix ECM Patch for cardiac repair and all other indications; Experimental/investigational: Corplex, Corplex P; Experimental/investigational: Cortiva Allograft Dermis (non-breast indications); Experimental/investigational: C-QUR biosynthetic mesh; Experimental/investigational: CRXa; Experimental/investigational: Cryo-Cord, CryoText; Experimental/investigational: CTM Boost Connective Tissue Matrix; Experimental/investigational: CYGNUS Amnion Patch Allografts, CYGNUS Disk, Cygnus Dual, CYGNUS Matrix, Cygnus Solo; Experimental/investigational: Cymetra injectable allograft for wound healing; Experimental/investigational: Cytal Burn Matrix, Cytal Multilayer Wound Matrix, Cytal Wound Matrix; Experimental/investigational: Dehydrated human amniotic membrane allograft (AmnioPro, BioFix, FlowerPatch); Experimental/investigational: DermaBind SL, DermaBind CH, DermaBind DL, DermaBind FM; Experimental/investigational: DermACELL for non-diabetic foot ulcer indications; Experimental/investigational: DermaClose RC continuous external tissue expander; Experimental/investigational: Dermacyte, Dermacyte AC Matrix Amniotic Membrane Allograft; Experimental/investigational: Derma-Gide; Experimental/investigational: Dermagraft for chronic foot ulcer secondary to necrotizing fasciitis; Experimental/investigational: DermaMatrix (formerly InteXen) Porcine Dermal Matrix for wound healing (non-breast); Experimental/investigational: DermaPure; Experimental/investigational: DermaSpan Acellular Dermal Matrix; Experimental/investigational: Dermavest Human Placental Connective Tissue Matrix; Experimental/investigational: Derm-Maxx; Experimental/investigational: Dermis on Demand (DOD) allografts; Experimental/investigational: DryFlex (human amnion allograft) for shoulder repair and all other indications; Experimental/investigational: Dual Layer Impax Membrane, Dual Layer Amnio Burgeon X-Membrane; Experimental/investigational: DuoAmnion; Experimental/investigational: Duograft AA, duoGRAFT AC; Experimental/investigational: DuraGen Plus dural regeneration matrix for soft tissue deficiencies and all other indications; Experimental/investigational: DuraMatrix; Experimental/investigational: Durepair Regeneration Matrix; Experimental/investigational: Emerge Matrix; Experimental/investigational: Enclose TL Matrix; Experimental/investigational: Endoform Dermal Template; Experimental/investigational: ENDURAGen; Experimental/investigational: Enverse; Experimental/investigational: TransCu O2 continuous diffusion oxygen therapy for wound healing; Experimental/investigational: EpiBurn; Experimental/investigational: Epidex; Experimental/investigational: Epieffect; Experimental/investigational: EPIFLO transdermal continuous oxygen therapy for wound healing; Experimental/investigational: EPIXPRESS; Experimental/investigational: Equine-derived decellularized collagen products (OrthADAPT, Unite, Unite Biomatrix); Experimental/investigational: Esano A, Esano AA, Esano AC, Esano ACA; Experimental/investigational: EZ Derm for wound healing and all other indications; Experimental/investigational: Evicel fibrin sealant for CSF leakage repair and all other indications; Experimental/investigational: Excellagen; Experimental/investigational: FlexHD acellular dermal matrix for wound healing (non-breast); Experimental/investigational: FloGraft Amniotic Fluid-Derived Allograft; Experimental/investigational: FlowerDerm, FlowerFlo (FlowerAmnioFlo), FlowerPatch (FlowerAMINOPatch); Experimental/investigational: Fluid Flow, Fluid GF; Experimental/investigational: Fortaderm, Fortaderm Antimicrobial; Experimental/investigational: Fortiva Porcine Dermis; Experimental/investigational: Foundation DRS Solo; Experimental/investigational: Gammagraft skin substitute; Experimental/investigational: Genesis Amniotic Membrane; Experimental/investigational: GORE BIO-A Fistula Plug; Experimental/investigational: Grafix cryo-preserved placental membrane, Grafix Plus; Experimental/investigational: GraftJacket Xpress injectable allograft for wound healing and all other indications; Experimental/investigational: GrowFX; Experimental/investigational: Guardian; Experimental/investigational: Helicoll; Experimental/investigational: Human Health Factor 10 Amniotic Patch (HHF10-P); Experimental/investigational: Hyalomatrix (hMatrix ADM) Tissue Reconstruction Matrix; Experimental/investigational: HydroFix; Experimental/investigational: In2Bone; Experimental/investigational: Inforce; Experimental/investigational: InnovaBurn, InnovaMatrix XL, InnovaMatrix AC, InnovaMatrix FS, InnovaMatrix PD; Experimental/investigational: Integra Wound Matrix, Integra Flowable Wound Matrix for osteoradionecrosis of jaw, wounds, pressure/venous/diabetic/chronic vascular ulcers, tunneled/undermined wounds, surgical wounds, trauma wounds, draining wounds and all other indications; Experimental/investigational: InteguPly; Experimental/investigational: Interfyl Human Connective Tissue Matrix; Experimental/investigational: Jacob's Ladder external closure device; Experimental/investigational: Keramatrix; Experimental/investigational: Kerasorb Wound Matrix; Experimental/investigational: Keroxx Flowable Wound Matrix; Experimental/investigational: Lamellas, Lamellas XT; Experimental/investigational: LiquidGen; Experimental/investigational: Mantle DL Matrix; Experimental/investigational: Marrow-derived augmentation for rotator cuff repair; Experimental/investigational: MatriDerm; Experimental/investigational: Matrion; Experimental/investigational: MatriStem Burn Matrix, MatriStem Micro Matrix, MatriStem UBM (Urinary Bladder Matrix), MatriStem Wound Matrix; Experimental/investigational: Matrix HD Allograft, Matrix HD Allograft Dermis; Experimental/investigational: Matrix PSM; Experimental/investigational: MediHoney; Experimental/investigational: Mediskin; Experimental/investigational: Medeor; Experimental/investigational: Membrane Graft, Membrane Wrap, Membrane Wrap-Hydro, Membrane Wrap-Lite; Experimental/investigational: MemoDerm; Experimental/investigational: Menaflex Collagen Meniscus Implant; Experimental/investigational: Meso BioMatrix; Experimental/investigational: MiAmnion for burns; Experimental/investigational: Microlyte Matrix; Experimental/investigational: MicroMatrix, MicroMatrix Flex; Experimental/investigational: Miro3D Fibers, Miro3D wound matrix, MIRODERM, MiroDry wound matrix, MiroTract Wound Matrix; Experimental/investigational: Mirragen Advanced Wound Matrix; Experimental/investigational: MLG Complete; Experimental/investigational: MOST; Experimental/investigational: mVASC (processed microvascular tissue); Experimental/investigational: MyOwn Skin; Experimental/investigational: Myriad matrix, Myriad Morcells, Myriad morselized allograft collagen powder for amputation stump dehiscence; Experimental/investigational: Neoform Dermis for wound healing (non-breast); Experimental/investigational: NeoGuard; Experimental/investigational: NeoMatriX Wound Matrix; Experimental/investigational: NeoPatch chorioamniotic membrane allograft; Experimental/investigational: NeoStim DL, NeoStim Membrane, NeoStim TL; Experimental/investigational: Neox Cord 1K, Neox 100, Neox Flo; Experimental/investigational: Neuragen; Experimental/investigational: Neuroflex; Experimental/investigational: Novachor; Experimental/investigational: Novafix, Novafix DL; Experimental/investigational: Novosorb BTM (Biodegradable Temporizing Matrix), NovoSorb SynPath dermal matrix; Experimental/investigational: NuCel liquid wound covering; Experimental/investigational: NuDyn, NuDYN DL, NuDYN DL MESH, NuDYN SL, NuDYN SLW; Experimental/investigational: Nuform; Experimental/investigational: NuShield, NuShield Orthopaedics, NuShield Spine; Experimental/investigational: Oasis burn matrix for wound healing and all other indications, Oasis Tri-Layer Matrix; Experimental/investigational: Ologen Collagen Matrix; Experimental/investigational: Omega3 MariGen, Omega3 MariGen Shield, Omega3 Wound ECM, Omega3 Wound Matrix (Kerecis fish skin graft); Experimental/investigational: Omeza Collagen Matrix; Experimental/investigational: Orion; Experimental/investigational: OrthADAPT Bioimplant (type I collagen scaffold) for tendon repair and all other indications; Experimental/investigational: OrthoFlo; Experimental/investigational: OsseoGuard; Experimental/investigational: Ovation; Experimental/investigational: Overlay SL Matrix; Experimental/investigational: OviTex (reinforced tissue matrix) for ventral hernia repair; Experimental/investigational: PalinGen Dual-Layer Membrane, PalinGen Flow, PalinGen Hydromembrane, PalinGen Membrane, Palingen SportFlow, PalinGen XPlus Hydromembrane, PalinGen XPlus Membrane; Experimental/investigational: Palisade DM Matrix; Experimental/investigational: ParaDerm dermal matrix; Experimental/investigational: Parietex Composite (PCO) Mesh for genito-urinary prolapse; Experimental/investigational: PelloGraft; Experimental/investigational: Peri-Guard Repair Patch; Experimental/investigational: Peri-Strips Dry, Peri-Strips Dry with Veritas Collagen Matrix; Experimental/investigational: Permacol Biologic Implant for soft tissue surgical repairs, hernia repair, muscle flap reinforcement, rectal prolapse, rectocele repair, abdominal wall defects, plastic/reconstructive surgery, complex abdominal wall repair and all other indications; Experimental/investigational: PermeaDerm B, PermeaDerm C, PermeaDerm Glove; Experimental/investigational: Phoenix Wound Matrix; Experimental/investigational: Placental tissue matrix allograft; Experimental/investigational: Plurivest Human Placental Connective Tissue Matrix; Experimental/investigational: PolyCyte; Experimental/investigational: Polygon3; Experimental/investigational: Porcine-derived decellularized collagen products (Collamend, Cuffpatch, Pelvicol, Pelvisoft); Experimental/investigational: Porcine-derived decellularized fetal skin products (Mediskin); Experimental/investigational: Porcine-derived polypropylene composite wound dressing (Avaulta Plus); Experimental/investigational: PriMatrix Dermal Repair Scaffold; Experimental/investigational: PRISMA matrix wound dressing for pressure ulcer; Experimental/investigational: Pro3-C amniotic membrane; Experimental/investigational: Procenta; Experimental/investigational: ProgenaMatrix; Experimental/investigational: ProLayer human allograft acellular dermal matrix; Experimental/investigational: ProMatrX ACF; Experimental/investigational: Promogran Matrix; Experimental/investigational: ProText; Experimental/investigational: ProxiCor (porcine extracellular matrix); Experimental/investigational: PTFE felt; Experimental/investigational: Puracol Collagen Wound Dressing, Puracol Plus Collagen Wound Dressing; Experimental/investigational: PuraPly Antimicrobial Wound Matrix (PuraPly AM), PuraPly Wound Matrix (PuraPly); Experimental/investigational: Puros Dermis; Experimental/investigational: Radiofrequency stimulation devices for wound healing; Experimental/investigational: Rampart DL Matrix; Experimental/investigational: Rebound Matrix; Experimental/investigational: RECELL Autologous Cell Harvesting Device; Experimental/investigational: Reeva FT; Experimental/investigational: RegeneLink Amniotic Membrane Allograft; Experimental/investigational: Reguard; Experimental/investigational: Relese; Experimental/investigational: Renew FT Matrix; Experimental/investigational: RenoGraft; Experimental/investigational: ReNu (amniotic membrane/fluid allograft); Experimental/investigational: Renuva; Experimental/investigational: Repliform; Experimental/investigational: Repriza; Experimental/investigational: Resolve Matrix; Experimental/investigational: Restorigin Amnion Patch, Restorigin Amniotic Fluid Therapy (AFT); Experimental/investigational: Restrata, Restrata Minimatrix; Experimental/investigational: Revita; Experimental/investigational: Revitalon; Experimental/investigational: RevioShield + Amniotic Barrier; Experimental/investigational: RHEO (BioStem Life Sciences); Experimental/investigational: SanoGraft; Experimental/investigational: Sanopellis; Experimental/investigational: Seamguard; Experimental/investigational: Sentry SL Matrix; Experimental/investigational: Shelter DM Matrix; Experimental/investigational: Simplichor; Experimental/investigational: SimpliGraft, SimpliMax; Experimental/investigational: Signature APatch; Experimental/investigational: Singlay; Experimental/investigational: SkinTE for burns; Experimental/investigational: Silver-coated wound dressings (Acticoat, Actisorb, Aquacel Ag, Granufoam silver VAC dressing, Mepitel Ag, Silversorb) for wound healing and all other indications; Experimental/investigational: Solana allograft; Experimental/investigational: Sonafine wound dressing; Experimental/investigational: SportMatrix, SportMesh; Experimental/investigational: SteriShield II dual layer amnion patch; Experimental/investigational: Strattice Reconstructive Tissue Matrix for wound healing (non-breast); Experimental/investigational: StrataGraft; Experimental/investigational: Stravix, Stravix PL; Experimental/investigational: Summit AC, Summit FX; Experimental/investigational: Supra SDRM; Experimental/investigational: Suprathel; Experimental/investigational: SurCord; Experimental/investigational: SureDerm; Experimental/investigational: SurFactor; Experimental/investigational: SurForce; Experimental/investigational: SurgiCORD; Experimental/investigational: surgiGRAFT, SurgiGRAFT-DUAL; Experimental/investigational: SurGraft FT, SurGraft TL, SurGraft XT, SurGraft; Experimental/investigational: SurgiMend for plastic/reconstructive surgery, muscle flap reinforcement, hernia repair, soft tissue reinforcement, tendon repair surgery reinforcement, and all other wound care indications (non-breast); Experimental/investigational: Surgisis (including Surgisis AFP Anal Fistula Plug, Surgisis Gold Hernia Repair Grafts, Surgisis Biodesign); Experimental/investigational: SurSight; Experimental/investigational: Symphony; Experimental/investigational: TAG; Experimental/investigational: Talymed; Experimental/investigational: TenoGlide tendon protector sheet (Tendon Wrap tendon protector) for tendon injury management and all other indications; Experimental/investigational: TenSIX Acellular Dermal Matrix for tendon repair and all other indications; Experimental/investigational: Texagen multi-layer amnion matrix; Experimental/investigational: Theracor P; Experimental/investigational: TheraForm Standard/Sheet Absorbable Collagen Membrane; Experimental/investigational: TheraGenesis; Experimental/investigational: TheraMend; Experimental/investigational: TissueMend for soft tissue repair/reinforcement by sutures/suture anchors during tendon repair, rotator cuff/patellar/Achilles/biceps/quadriceps/other tendon reinforcement, and all other indications; Experimental/investigational: Tornier BioFiber Absorbable Biological Scaffold, Tornier Collagen Coated BioFiber Scaffold; Experimental/investigational: TOTAL; Experimental/investigational: triGRAFT FT; Experimental/investigational: Tri-Membrane Wrap; Experimental/investigational: Truskin; Experimental/investigational: Unite Biomatrix; Experimental/investigational: Vaso Shield; Experimental/investigational: Veritas Collagen Matrix for soft tissue deficiency surgical repair implant and all other indications; Experimental/investigational: VersaWrap Tendon Protector for tendon injury management and all other indications; Experimental/investigational: Vitagel surgical hemostat for wound healing and all other indications; Experimental/investigational: Vendaje, Vendaje AC (BioStem Life Sciences); Experimental/investigational: VIA Matrix; Experimental/investigational: VIM Human Amniotic Membrane; Experimental/investigational: VitoGraft; Experimental/investigational: WoundEx Flow, WoundEx Membrane; Experimental/investigational: WoundFix Membrane, WoundFix Plus Membrane, WoundFix XPlus Membrane; Experimental/investigational: WoundPlus Membrane or E-graft; Experimental/investigational: Xceed TL Matrix; Experimental/investigational: Xcell Amino Matrix; Experimental/investigational: XCellerate; Experimental/investigational: XCM Biologic Tissue Matrix; Experimental/investigational: Xelma; Experimental/investigational: XcelliStem; Experimental/investigational: XenMatrix; Experimental/investigational: X-Repair; Experimental/investigational: Xwrap 2.0, Xwrap Amniotic Membrane-Derived Allograft, XWrap Dry, XWRAP Dual, Xwrap Dual Plus, Xwrap Fenestra Plus, Xwrap Hydro, Xwrap Hydro Plus, XWRAP Plus, Xwrap Tribus; Experimental/investigational: Zenith Amniotic Membrane; Contraindication (basis for non-coverage): Dermagraft is contraindicated in infected ulcers and ulcers with sinus tracts. Claims may be denied when the requested service falls under these.

Does Aetna require prior authorization for Wound Care (Skin and Soft Tissue Substitutes)?

Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Documentation: Attestation of non-smoker status OR completion of / enrollment in smoking cessation therapy; Documentation of wound characteristics and treatment plan, with a photo that includes a ruler; Photographic documentation with a ruler for continuation of therapy; Evidence in the member's medical record of wound improvement; Wound measurements taken at intervals of no more than every 14 days to demonstrate progressive healing; Medical records, test results, and provider credentials as part of coverage determination, quality improvement, and fraud/waste/abuse prevention processes.

What does Aetna exclude for Wound Care (Skin and Soft Tissue Substitutes)?

Policy exclusions and limitations: Not medically necessary: any indications not listed in the clinical criteria section; Not medically necessary: pressure ulcer treatment; Not medically necessary: continued treatment when the ulcer fails to heal by >=50% within the first 6 weeks; Not medically necessary: treatment beyond 12 weeks regardless of wound status; Not medically necessary: continued use after treatment failure (repeat or alternative application within one year for venous stasis or diabetic foot ulcer); Not medically necessary: repair following Mohs surgery; Not medically necessary: retreatment of healed ulcers (>=75% size reduction, smaller than 1 cm^2); Experimental/investigational: MariGen for diabetic foot ulcer wounds; Not separately reimbursable: Cryolife BioGlue (considered incidental to surgery); Not separately reimbursed: Tisseel (integral to surgery); Not separately reimbursed: DuraSeal (integral to dural repair during spinal surgery); Experimental/investigational: Abiomend Membrane, Abiomend Hydromembrane, Abiomend Xplus Membrane, Abiomend Xplus Hydromembrane; Experimental/investigational: Absolv3 Membrane; Experimental/investigational: ACApatch; Experimental/investigational: Acesso, Acesso AC, Acesso DL, Acesso TL; Experimental/investigational: ACM Surgical Collagen, ACM Surgical Extra Advanced Collagen, ACM Surgical Extra Advanced Collagen Powder; Experimental/investigational: ActiGraft; Experimental/investigational: AC5 Advanced Wound System; Experimental/investigational: Activate Matrix; Experimental/investigational: Adherus Dural Sealant; Experimental/investigational: AdvoGraft Membrane Dual, AdvoGraft One; Experimental/investigational: AeroGuard; Experimental/investigational: Affinity Human Amniotic Allograft; Experimental/investigational: Alexiguard dl-t, Alexiguard sl-t, Alexiguard tl-t; Experimental/investigational: Allacor P; Experimental/investigational: AlloDerm for carotid artery protection post-radical neck dissection; Experimental/investigational: AlloGen, AlloGen Liquid; Experimental/investigational: AlloMax (non-breast indications); Experimental/investigational: alloPLY; Experimental/investigational: AlloSkin AC Acellular Dermal Matrix, AlloSkin RT; Experimental/investigational: AlloWrap; Experimental/investigational: AlphaGems amniotic tissue allograft; Experimental/investigational: AltiPlast, AltiPly; Experimental/investigational: Ambio Choice amniotic membrane; Experimental/investigational: Amchomatrix dl, Amniomatrix f4x; Experimental/investigational: AmchoPlast, AmchoPlast EXCEL, AmchoPlast FD, AmchoThick; Experimental/investigational: American Amnion, American Amnion AC, American Amnion AC Tri-Layer; Experimental/investigational: Amnioamp-mp; Experimental/investigational: AmnioArmor; Experimental/investigational: Amnio Burgeon Dual-Layer Membrane, Amnio Burgeon Membrane/Hydromembrane, Amnio Burgeon XPlus Membrane/XPlus Hydromembrane; Experimental/investigational: AmnioCare; Experimental/investigational: AmnioCord; Experimental/investigational: AmnioCore Pro, AmnioCore Pro+, AmnioCore SL; Experimental/investigational: AmnioCyte Plus; Experimental/investigational: AmnioDefend FT Matrix; Experimental/investigational: AmnioExCel; Experimental/investigational: AmnioFill Human Placental Tissue Allograft; Experimental/investigational: AmnioFix Amnion/Chorion Membrane Allograft; Experimental/investigational: Amnio FRT; Experimental/investigational: AmnioGenix; Experimental/investigational: AmnioHeal amniotic membrane; Experimental/investigational: Amniomatrix Human Amniotic Suspension Allograft, Amniomatrix f3x; Experimental/investigational: Amnio-Maxx, Amnio-Maxx Lite; Experimental/investigational: AmnioMTM; Experimental/investigational: Amnion allograft ASG; Experimental/investigational: Amnion Bio; Experimental/investigational: AmnioPlast 1, AmnioPlast 2, AmnioPlast 3; Experimental/investigational: Amnio Quad-Core; Experimental/investigational: Amniorepair; Experimental/investigational: Amnios' acellular liquid amnion; Experimental/investigational: AmnioShield; Experimental/investigational: AmnioStrip; Experimental/investigational: Amniotext (suspension/patch); Experimental/investigational: Amnio Tri-Core; Experimental/investigational: AmnioTX; Experimental/investigational: Amnio Wound; Experimental/investigational: AmnioWrap2; Experimental/investigational: Amniotic fluid injection for wound/corneal wound healing and adhesion prevention post-orthopedic surgery; Experimental/investigational: Amniox (human embryonic membrane) for tarsal tunnel repair and all other indications; Experimental/investigational: Amniply; Experimental/investigational: AmnyoFactor; Experimental/investigational: AmnyoFluid; Experimental/investigational: Apis; Experimental/investigational: Apligraf for necrotizing lesions; Experimental/investigational: Architect ECM, Architect PX; Experimental/investigational: ArdeoGraft; Experimental/investigational: Artacent C, Artacent Cord, Artacent Trident, Artacent Velos, Artacent VeriClen, Artacent Wound; Experimental/investigational: Artelon (poly[urethane urea] elastomer) for ACL reconstruction, rotator cuff repair, trapezio-metacarpal joint osteoarthritis and all other indications; Experimental/investigational: Arthres GraftRope for AC joint separation reconstruction; Experimental/investigational: Arthrex Amnion matrix, Arthrex Amnion viscous; Experimental/investigational: Arthroflex (FlexGraft); Experimental/investigational: Ascent (injectable from human amniotic fluid); Experimental/investigational: Autologous blood-derived products (PRP, platelet gel, growth factors — Autologel, Procuren, SafeBlood); Experimental/investigational: Autologous fat for scars; Experimental/investigational: Avotermin for skin scarring improvement; Experimental/investigational: AxoBioMembrane; Experimental/investigational: Axolotl Ambient, Axolotl Cryo, Axolotl DualGraft, Axolotl Graft; Experimental/investigational: Barrera SL, Barrera DL; Experimental/investigational: BellaCell HD; Experimental/investigational: BioDexcel; Experimental/investigational: BioDfactor Viable Tissue Matrix; Experimental/investigational: BioDfence human amniotic allograft, BioDfence Dryflex; Experimental/investigational: BioDmatrix; Experimental/investigational: BioDRestore Elemental Tissue Matrix; Experimental/investigational: Bio-ConneKt; Experimental/investigational: BioFix Amniotic Membrane Allograft, BioFix Flow Placental Tissue Matrix Allograft; Experimental/investigational: Bioinductive implant Regeneten; Experimental/investigational: Bionect; Experimental/investigational: BioSkin Flow; Experimental/investigational: Biostat Biologx fibrin sealant for wound healing and all other indications; Experimental/investigational: Biotape reinforcement matrix for soft tissue augmentation and all other indications; Experimental/investigational: Biovance Amniotic Membrane Allograft, Biovance Tri-layer, Biovance 3L; Experimental/investigational: BioWound Membrane, BioWound Plus Membrane, BioWound XPlus Membrane; Experimental/investigational: CaregraFT; Experimental/investigational: carePATCH; Experimental/investigational: celera Dual Membrane, celera Dual Layer; Experimental/investigational: CellECT (human amnion/amniotic fluid allograft); Experimental/investigational: CellerateRX; Experimental/investigational: Cellesta Cord, Cellesta Duo, Cellesta Flowable Amnion; Experimental/investigational: Cellgenuity amniotic fluid; Experimental/investigational: Choriofix; Experimental/investigational: Choriply; Experimental/investigational: Clarix 100, Clarix Cord 1K, Clarix Flo; Experimental/investigational: Cocoon Membrane; Experimental/investigational: Cogenex amniotic membrane, Cogenex Flowable Amnion; Experimental/investigational: CollaFix; Experimental/investigational: Colla-Pad; Experimental/investigational: CollaSorb collagen dressing; Experimental/investigational: CollaWound collagen sponge; Experimental/investigational: Coll-e-Derm; Experimental/investigational: Collexa; Experimental/investigational: Complete AA, Complete ACA, Complete FT, Complete SL; Experimental/investigational: Conexa reconstructive tissue matrix; Experimental/investigational: Cook Medical anal fistula plug; Experimental/investigational: CoreCyte, CoreText; Experimental/investigational: CorMatrix ECM Patch for cardiac repair and all other indications; Experimental/investigational: Corplex, Corplex P; Experimental/investigational: Cortiva Allograft Dermis (non-breast indications); Experimental/investigational: C-QUR biosynthetic mesh; Experimental/investigational: CRXa; Experimental/investigational: Cryo-Cord, CryoText; Experimental/investigational: CTM Boost Connective Tissue Matrix; Experimental/investigational: CYGNUS Amnion Patch Allografts, CYGNUS Disk, Cygnus Dual, CYGNUS Matrix, Cygnus Solo; Experimental/investigational: Cymetra injectable allograft for wound healing; Experimental/investigational: Cytal Burn Matrix, Cytal Multilayer Wound Matrix, Cytal Wound Matrix; Experimental/investigational: Dehydrated human amniotic membrane allograft (AmnioPro, BioFix, FlowerPatch); Experimental/investigational: DermaBind SL, DermaBind CH, DermaBind DL, DermaBind FM; Experimental/investigational: DermACELL for non-diabetic foot ulcer indications; Experimental/investigational: DermaClose RC continuous external tissue expander; Experimental/investigational: Dermacyte, Dermacyte AC Matrix Amniotic Membrane Allograft; Experimental/investigational: Derma-Gide; Experimental/investigational: Dermagraft for chronic foot ulcer secondary to necrotizing fasciitis; Experimental/investigational: DermaMatrix (formerly InteXen) Porcine Dermal Matrix for wound healing (non-breast); Experimental/investigational: DermaPure; Experimental/investigational: DermaSpan Acellular Dermal Matrix; Experimental/investigational: Dermavest Human Placental Connective Tissue Matrix; Experimental/investigational: Derm-Maxx; Experimental/investigational: Dermis on Demand (DOD) allografts; Experimental/investigational: DryFlex (human amnion allograft) for shoulder repair and all other indications; Experimental/investigational: Dual Layer Impax Membrane, Dual Layer Amnio Burgeon X-Membrane; Experimental/investigational: DuoAmnion; Experimental/investigational: Duograft AA, duoGRAFT AC; Experimental/investigational: DuraGen Plus dural regeneration matrix for soft tissue deficiencies and all other indications; Experimental/investigational: DuraMatrix; Experimental/investigational: Durepair Regeneration Matrix; Experimental/investigational: Emerge Matrix; Experimental/investigational: Enclose TL Matrix; Experimental/investigational: Endoform Dermal Template; Experimental/investigational: ENDURAGen; Experimental/investigational: Enverse; Experimental/investigational: TransCu O2 continuous diffusion oxygen therapy for wound healing; Experimental/investigational: EpiBurn; Experimental/investigational: Epidex; Experimental/investigational: Epieffect; Experimental/investigational: EPIFLO transdermal continuous oxygen therapy for wound healing; Experimental/investigational: EPIXPRESS; Experimental/investigational: Equine-derived decellularized collagen products (OrthADAPT, Unite, Unite Biomatrix); Experimental/investigational: Esano A, Esano AA, Esano AC, Esano ACA; Experimental/investigational: EZ Derm for wound healing and all other indications; Experimental/investigational: Evicel fibrin sealant for CSF leakage repair and all other indications; Experimental/investigational: Excellagen; Experimental/investigational: FlexHD acellular dermal matrix for wound healing (non-breast); Experimental/investigational: FloGraft Amniotic Fluid-Derived Allograft; Experimental/investigational: FlowerDerm, FlowerFlo (FlowerAmnioFlo), FlowerPatch (FlowerAMINOPatch); Experimental/investigational: Fluid Flow, Fluid GF; Experimental/investigational: Fortaderm, Fortaderm Antimicrobial; Experimental/investigational: Fortiva Porcine Dermis; Experimental/investigational: Foundation DRS Solo; Experimental/investigational: Gammagraft skin substitute; Experimental/investigational: Genesis Amniotic Membrane; Experimental/investigational: GORE BIO-A Fistula Plug; Experimental/investigational: Grafix cryo-preserved placental membrane, Grafix Plus; Experimental/investigational: GraftJacket Xpress injectable allograft for wound healing and all other indications; Experimental/investigational: GrowFX; Experimental/investigational: Guardian; Experimental/investigational: Helicoll; Experimental/investigational: Human Health Factor 10 Amniotic Patch (HHF10-P); Experimental/investigational: Hyalomatrix (hMatrix ADM) Tissue Reconstruction Matrix; Experimental/investigational: HydroFix; Experimental/investigational: In2Bone; Experimental/investigational: Inforce; Experimental/investigational: InnovaBurn, InnovaMatrix XL, InnovaMatrix AC, InnovaMatrix FS, InnovaMatrix PD; Experimental/investigational: Integra Wound Matrix, Integra Flowable Wound Matrix for osteoradionecrosis of jaw, wounds, pressure/venous/diabetic/chronic vascular ulcers, tunneled/undermined wounds, surgical wounds, trauma wounds, draining wounds and all other indications; Experimental/investigational: InteguPly; Experimental/investigational: Interfyl Human Connective Tissue Matrix; Experimental/investigational: Jacob's Ladder external closure device; Experimental/investigational: Keramatrix; Experimental/investigational: Kerasorb Wound Matrix; Experimental/investigational: Keroxx Flowable Wound Matrix; Experimental/investigational: Lamellas, Lamellas XT; Experimental/investigational: LiquidGen; Experimental/investigational: Mantle DL Matrix; Experimental/investigational: Marrow-derived augmentation for rotator cuff repair; Experimental/investigational: MatriDerm; Experimental/investigational: Matrion; Experimental/investigational: MatriStem Burn Matrix, MatriStem Micro Matrix, MatriStem UBM (Urinary Bladder Matrix), MatriStem Wound Matrix; Experimental/investigational: Matrix HD Allograft, Matrix HD Allograft Dermis; Experimental/investigational: Matrix PSM; Experimental/investigational: MediHoney; Experimental/investigational: Mediskin; Experimental/investigational: Medeor; Experimental/investigational: Membrane Graft, Membrane Wrap, Membrane Wrap-Hydro, Membrane Wrap-Lite; Experimental/investigational: MemoDerm; Experimental/investigational: Menaflex Collagen Meniscus Implant; Experimental/investigational: Meso BioMatrix; Experimental/investigational: MiAmnion for burns; Experimental/investigational: Microlyte Matrix; Experimental/investigational: MicroMatrix, MicroMatrix Flex; Experimental/investigational: Miro3D Fibers, Miro3D wound matrix, MIRODERM, MiroDry wound matrix, MiroTract Wound Matrix; Experimental/investigational: Mirragen Advanced Wound Matrix; Experimental/investigational: MLG Complete; Experimental/investigational: MOST; Experimental/investigational: mVASC (processed microvascular tissue); Experimental/investigational: MyOwn Skin; Experimental/investigational: Myriad matrix, Myriad Morcells, Myriad morselized allograft collagen powder for amputation stump dehiscence; Experimental/investigational: Neoform Dermis for wound healing (non-breast); Experimental/investigational: NeoGuard; Experimental/investigational: NeoMatriX Wound Matrix; Experimental/investigational: NeoPatch chorioamniotic membrane allograft; Experimental/investigational: NeoStim DL, NeoStim Membrane, NeoStim TL; Experimental/investigational: Neox Cord 1K, Neox 100, Neox Flo; Experimental/investigational: Neuragen; Experimental/investigational: Neuroflex; Experimental/investigational: Novachor; Experimental/investigational: Novafix, Novafix DL; Experimental/investigational: Novosorb BTM (Biodegradable Temporizing Matrix), NovoSorb SynPath dermal matrix; Experimental/investigational: NuCel liquid wound covering; Experimental/investigational: NuDyn, NuDYN DL, NuDYN DL MESH, NuDYN SL, NuDYN SLW; Experimental/investigational: Nuform; Experimental/investigational: NuShield, NuShield Orthopaedics, NuShield Spine; Experimental/investigational: Oasis burn matrix for wound healing and all other indications, Oasis Tri-Layer Matrix; Experimental/investigational: Ologen Collagen Matrix; Experimental/investigational: Omega3 MariGen, Omega3 MariGen Shield, Omega3 Wound ECM, Omega3 Wound Matrix (Kerecis fish skin graft); Experimental/investigational: Omeza Collagen Matrix; Experimental/investigational: Orion; Experimental/investigational: OrthADAPT Bioimplant (type I collagen scaffold) for tendon repair and all other indications; Experimental/investigational: OrthoFlo; Experimental/investigational: OsseoGuard; Experimental/investigational: Ovation; Experimental/investigational: Overlay SL Matrix; Experimental/investigational: OviTex (reinforced tissue matrix) for ventral hernia repair; Experimental/investigational: PalinGen Dual-Layer Membrane, PalinGen Flow, PalinGen Hydromembrane, PalinGen Membrane, Palingen SportFlow, PalinGen XPlus Hydromembrane, PalinGen XPlus Membrane; Experimental/investigational: Palisade DM Matrix; Experimental/investigational: ParaDerm dermal matrix; Experimental/investigational: Parietex Composite (PCO) Mesh for genito-urinary prolapse; Experimental/investigational: PelloGraft; Experimental/investigational: Peri-Guard Repair Patch; Experimental/investigational: Peri-Strips Dry, Peri-Strips Dry with Veritas Collagen Matrix; Experimental/investigational: Permacol Biologic Implant for soft tissue surgical repairs, hernia repair, muscle flap reinforcement, rectal prolapse, rectocele repair, abdominal wall defects, plastic/reconstructive surgery, complex abdominal wall repair and all other indications; Experimental/investigational: PermeaDerm B, PermeaDerm C, PermeaDerm Glove; Experimental/investigational: Phoenix Wound Matrix; Experimental/investigational: Placental tissue matrix allograft; Experimental/investigational: Plurivest Human Placental Connective Tissue Matrix; Experimental/investigational: PolyCyte; Experimental/investigational: Polygon3; Experimental/investigational: Porcine-derived decellularized collagen products (Collamend, Cuffpatch, Pelvicol, Pelvisoft); Experimental/investigational: Porcine-derived decellularized fetal skin products (Mediskin); Experimental/investigational: Porcine-derived polypropylene composite wound dressing (Avaulta Plus); Experimental/investigational: PriMatrix Dermal Repair Scaffold; Experimental/investigational: PRISMA matrix wound dressing for pressure ulcer; Experimental/investigational: Pro3-C amniotic membrane; Experimental/investigational: Procenta; Experimental/investigational: ProgenaMatrix; Experimental/investigational: ProLayer human allograft acellular dermal matrix; Experimental/investigational: ProMatrX ACF; Experimental/investigational: Promogran Matrix; Experimental/investigational: ProText; Experimental/investigational: ProxiCor (porcine extracellular matrix); Experimental/investigational: PTFE felt; Experimental/investigational: Puracol Collagen Wound Dressing, Puracol Plus Collagen Wound Dressing; Experimental/investigational: PuraPly Antimicrobial Wound Matrix (PuraPly AM), PuraPly Wound Matrix (PuraPly); Experimental/investigational: Puros Dermis; Experimental/investigational: Radiofrequency stimulation devices for wound healing; Experimental/investigational: Rampart DL Matrix; Experimental/investigational: Rebound Matrix; Experimental/investigational: RECELL Autologous Cell Harvesting Device; Experimental/investigational: Reeva FT; Experimental/investigational: RegeneLink Amniotic Membrane Allograft; Experimental/investigational: Reguard; Experimental/investigational: Relese; Experimental/investigational: Renew FT Matrix; Experimental/investigational: RenoGraft; Experimental/investigational: ReNu (amniotic membrane/fluid allograft); Experimental/investigational: Renuva; Experimental/investigational: Repliform; Experimental/investigational: Repriza; Experimental/investigational: Resolve Matrix; Experimental/investigational: Restorigin Amnion Patch, Restorigin Amniotic Fluid Therapy (AFT); Experimental/investigational: Restrata, Restrata Minimatrix; Experimental/investigational: Revita; Experimental/investigational: Revitalon; Experimental/investigational: RevioShield + Amniotic Barrier; Experimental/investigational: RHEO (BioStem Life Sciences); Experimental/investigational: SanoGraft; Experimental/investigational: Sanopellis; Experimental/investigational: Seamguard; Experimental/investigational: Sentry SL Matrix; Experimental/investigational: Shelter DM Matrix; Experimental/investigational: Simplichor; Experimental/investigational: SimpliGraft, SimpliMax; Experimental/investigational: Signature APatch; Experimental/investigational: Singlay; Experimental/investigational: SkinTE for burns; Experimental/investigational: Silver-coated wound dressings (Acticoat, Actisorb, Aquacel Ag, Granufoam silver VAC dressing, Mepitel Ag, Silversorb) for wound healing and all other indications; Experimental/investigational: Solana allograft; Experimental/investigational: Sonafine wound dressing; Experimental/investigational: SportMatrix, SportMesh; Experimental/investigational: SteriShield II dual layer amnion patch; Experimental/investigational: Strattice Reconstructive Tissue Matrix for wound healing (non-breast); Experimental/investigational: StrataGraft; Experimental/investigational: Stravix, Stravix PL; Experimental/investigational: Summit AC, Summit FX; Experimental/investigational: Supra SDRM; Experimental/investigational: Suprathel; Experimental/investigational: SurCord; Experimental/investigational: SureDerm; Experimental/investigational: SurFactor; Experimental/investigational: SurForce; Experimental/investigational: SurgiCORD; Experimental/investigational: surgiGRAFT, SurgiGRAFT-DUAL; Experimental/investigational: SurGraft FT, SurGraft TL, SurGraft XT, SurGraft; Experimental/investigational: SurgiMend for plastic/reconstructive surgery, muscle flap reinforcement, hernia repair, soft tissue reinforcement, tendon repair surgery reinforcement, and all other wound care indications (non-breast); Experimental/investigational: Surgisis (including Surgisis AFP Anal Fistula Plug, Surgisis Gold Hernia Repair Grafts, Surgisis Biodesign); Experimental/investigational: SurSight; Experimental/investigational: Symphony; Experimental/investigational: TAG; Experimental/investigational: Talymed; Experimental/investigational: TenoGlide tendon protector sheet (Tendon Wrap tendon protector) for tendon injury management and all other indications; Experimental/investigational: TenSIX Acellular Dermal Matrix for tendon repair and all other indications; Experimental/investigational: Texagen multi-layer amnion matrix; Experimental/investigational: Theracor P; Experimental/investigational: TheraForm Standard/Sheet Absorbable Collagen Membrane; Experimental/investigational: TheraGenesis; Experimental/investigational: TheraMend; Experimental/investigational: TissueMend for soft tissue repair/reinforcement by sutures/suture anchors during tendon repair, rotator cuff/patellar/Achilles/biceps/quadriceps/other tendon reinforcement, and all other indications; Experimental/investigational: Tornier BioFiber Absorbable Biological Scaffold, Tornier Collagen Coated BioFiber Scaffold; Experimental/investigational: TOTAL; Experimental/investigational: triGRAFT FT; Experimental/investigational: Tri-Membrane Wrap; Experimental/investigational: Truskin; Experimental/investigational: Unite Biomatrix; Experimental/investigational: Vaso Shield; Experimental/investigational: Veritas Collagen Matrix for soft tissue deficiency surgical repair implant and all other indications; Experimental/investigational: VersaWrap Tendon Protector for tendon injury management and all other indications; Experimental/investigational: Vitagel surgical hemostat for wound healing and all other indications; Experimental/investigational: Vendaje, Vendaje AC (BioStem Life Sciences); Experimental/investigational: VIA Matrix; Experimental/investigational: VIM Human Amniotic Membrane; Experimental/investigational: VitoGraft; Experimental/investigational: WoundEx Flow, WoundEx Membrane; Experimental/investigational: WoundFix Membrane, WoundFix Plus Membrane, WoundFix XPlus Membrane; Experimental/investigational: WoundPlus Membrane or E-graft; Experimental/investigational: Xceed TL Matrix; Experimental/investigational: Xcell Amino Matrix; Experimental/investigational: XCellerate; Experimental/investigational: XCM Biologic Tissue Matrix; Experimental/investigational: Xelma; Experimental/investigational: XcelliStem; Experimental/investigational: XenMatrix; Experimental/investigational: X-Repair; Experimental/investigational: Xwrap 2.0, Xwrap Amniotic Membrane-Derived Allograft, XWrap Dry, XWRAP Dual, Xwrap Dual Plus, Xwrap Fenestra Plus, Xwrap Hydro, Xwrap Hydro Plus, XWRAP Plus, Xwrap Tribus; Experimental/investigational: Zenith Amniotic Membrane; Contraindication (basis for non-coverage): Dermagraft is contraindicated in infected ulcers and ulcers with sinus tracts. Claims may be denied when the requested service falls under these.

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