A6216

  • Gauze, Non-Impregnated (A6216-A6221, A6402-A6404, A6407)

Non-impregnated gauze dressing change is up to 3 times per day for a dressing without a border and once per day for a dressing with a border. It is usually not reasonable and necessary to stack more than 2 gauze pads on top of each other in any one area

A6252

  • Specialty Absorptive Dressing (A6251-A6256)

Specialty absorptive dressings are covered when used for moderately or highly exudative full thickness wounds (e.g., stage III or IV ulcers). Specialty absorptive dressing change is up to once per day for a dressing without an adhesive border and up to every other day for a dressing with a border.

A6197

  • Alginate Or Other Fiber Gelling Dressing (A6196-A6199)

Alginate or other fiber gelling dressing covers are covered for moderately to highly exudative full thickness wounds (e.g., stage III or IV ulcers); and alginate or other fiber gelling dressing fillers for moderately to highly exudative full thickness wound cavities (e.g., stage III or IV ulcers). They are not reasonable and necessary on dry wounds or wounds covered with eschar. Dressing change is up to once per day. One wound cover sheet of the approximate size of the wound or up to 2 units of wound filler (1 unit = 6 inches of alginate or other fiber gelling dressing rope) is used at each dressing change.

A5120

  • 150 per 6 months

A4344

  • No more than one catheter per month is covered for routine catheter maintenance. Non-routine catheter changes are covered when documentation substantiates medical necessity, such as for the following indications:

Catheter is accidentally removed (e.g., pulled out by beneficiary)
Malfunction of catheter (e.g., balloon does not stay inflated, hole in catheter)
Malfunction of catheter (e.g., balloon does not stay inflated, hole in catheter)
Catheter is obstructed by encrustation, mucous plug, or blood clot
History of recurrent obstruction or urinary tract infection for which it has been established that an acute
event is prevented by a scheduled change frequency of more than once per month

A4310

  • CATHETER INSERTION TRAY (A4310-A4316, A4353, and A4354)

One insertion tray will be covered per episode of indwelling catheter insertion. More than one tray per episode will be denied as not reasonable and necessary.

A4357

  • 2 per month