Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve an application of skin substitute graft to face, scalp, eyelids, 
mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area up to 100 sq 
cm; first 25 sq cm or less wound surface area (15275) and Cogenex amniotic membrane, per square centimeter 
(Q4229). 
 
You asked the Plan to pre-approve a skin substitute graft. You say that you will be performing Mohs surgery 
on the enrollees left ear to remove a squamous cell carcinoma in-situ with follicular extension on his left 
tragus. There is a difficulty of closure for this location and the use of Cogenex to close the wound will decrease 
pain, decrease risk of infection, and avoid anatomic distortion in the area. The Plan denied your request. The 
Plan says that the request does not meet the Medicare or health plan coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
 
 
 
 
 
 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve skin substitute graft. Our reviewer says 
that the requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found that the ear is a region that has a high prevalence of cutaneous carcinomas, and several 
guidelines indicate Mohs micrographic surgery as the first-choice treatment in such cases. Although the 
technique allows maximum preservation of healthy tissue, many auricular surgical wounds constitute a 
challenge due to the peculiar local anatomy, with evident curves and reliefs. When closure is not feasible, 
Mohs micrographic surgical wounds typically are left to heal by secondary intention and require weeks to 
close. Cogenex, a fenestrated dehydrated complete human placental membrane allograft, is designed for use as 
a selective barrier to protect chronic and acute wounds from the surrounding environment. Fenestration of the 
allograft creates a selective barrier with channels that allow wound fluid to drain. Research data indicate that 
skin substitute treatment is beneficial to promote wound healing and improve cosmetic outcomes of post-Mohs 
surgical wounds. The enrollee meets criteria for approval to avoid serious complications. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of skin substitute graft have been met. Therefore, we decided that the Plan has to 
pre-approve an application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, 
hands, feet, and/or multiple digits, total wound surface area up to 100 sq cm; first 25 sq cm or less wound 
surface area (15275) and Cogenex amniotic membrane, per square centimeter (Q4229).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.