#BIOTECH UNDERGROUND PURE 6 EXTREME FORMULA SKIN#
Īetna considers AlloPatch medically necessary for the treatment of partial and full‐thickness neuropathic diabetic foot ulcers that are greater than 6 weeks in duration with no capsule, tendon or bone exposed, when used in conjunction with standard diabetic ulcer care.Īetna considers AmnioBand medically necessary for the treatment of partial and full‐thickness neuropathic diabetic foot ulcers that are greater than 6 weeks in duration with no capsule, tendon or bone exposed, when used in conjunction with standard diabetic ulcer care.Īetna considers a culture-derived human skin equivalent (HSE) called Apligraf (graftskin) medically necessary for any of the following indications:
Aetna considers the use of Alloderm experimental and investigational for all other indications (e.g., hernia repair, reduction of incidence of Frey's syndrome following parotidectomy, repair of trans-sphincteric rectal fistula, and for use in reconstruction of the upper extremity) because its effectiveness for indications other than the one listed above has not been established.Aetna considers AlloDerm and Alloderm-RTU acellular dermal tissue matrix medically necessary for ear drum augmentation (tympanoplasty), repair of skull base defect, and temporal bone lining.Aetna considers Alloderm and Alloderm-RTU acellular dermal tissue matrix medically necessary for use in surgical repair of complex abdominal wall wounds (e.g., due to infection, fascial defect, etc.).Aetna considers Alloderm and Alloderm-RTU acellular dermal tissue matrix medically necessary for breast reconstructive surgery (see CPB 0185 - Breast Reconstruction Surgery).Medically Necessary Skin and Soft Tissue SubstitutesĪetna considers the following skin and soft tissue substitute products medically necessary for wound care according to the criteria indicated below:.Table Of Contents Policy Applicable CPT / HCPCS / ICD-10 Codes Background References
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