Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Grafix core and grafixpl core, per square centimeter 
(Q4132), Grafix prime, grafixpl prime, stravix and stravixpl, per square centimeter (Q4133), 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 
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; each additional 25 sq cm wound surface area, 
or part thereof (15276). 
 
You asked the Plan to pre-approve skin graft procedures. You say that the enrollee is not safe to go without this 
procedure. The enrollee has new wounds. The Plan denied your request. The Plan says records do not show that 
the enrollee's wound has failed to respond to standard treatment. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 graft procedures. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found after careful review of the enclosed information and the pertinent guidelines for this 
case, the requested Grafix Core or Prime skin substitute applications for the right first MPJ ulcer are not 
medically reasonable or necessary. The medical documentation establishes that although this injured worker 
does continue to demonstrate ulcerations to the right foot, it is also clearly noted that these ulcerations are 
healing/reducing in size with routine debridement, dressings, and offloading. Medicare covered indication 
guidelines advise that skin and skin substitutes are recommended for chronic wounds, defined as wounds that 
do not respond to standard wound treatment for at least a 30-day period during organized comprehensive 
conservative therapy. The medical documentation advises that this injured workers ulcerations are 
healing/responding to routine wound care including debridement. Therefore, the enrollee does not meet the 
criteria for approval for the requested application of skin and skin substitutes. It does not appear that the skin 
and skin substitute applications are medically reasonable or necessary for the enrollee at this time. 
 
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 graft procedures have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Grafix core and grafixpl core, per square centimeter (Q4132), Grafix prime, 
grafixpl prime, stravix and stravixpl, per square centimeter (Q4133), 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 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; each additional 25 sq cm wound surface area, or part thereof (15276).