Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the sterile water, saline and/or dextrose, diluent/flush, 10 ml 
(A4216-A1 x50), gauze, non-impregnated, non-sterile, pad size 16 sq. in. or less, without adhesive border, each 
dressing (A6216-A1 x200), ostomy skin barrier, pectin-based, paste, per ounce (A4406-A1 x8), collagen 
dressing, sterile, size 16 sq. in. or less, each (A6021-A1 x4), foam dressing, wound cover, sterile, pad size 16 
sq. in. or less, with any size adhesive border, each dressing (A6212 x20) provided on November 3, 2022. 
 
You asked the Plan to pay for the items. You say that the claim should not have denied, and you are asking the 
Health Plan to review medical records and process claim based on medical necessity. The Plan denied your 
request. The Plan says there is no documentation of an ostomy and the wound care notes do not document the 
use of an ostomy skin barrier. The Plan states the wound care notes do not document the use of a collagen 
dressing. The Plan states the wound care notes document foam filler and there was no foam dressing utilized. 
The Plan states A6215 represents foam filler which was not billed. 
 
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 pay for the items. Our physician reviewer found 
with regard to collagen dressing (A6021), guidance is identified in LCD L33831. In this case, the wound care 
notes did not document the use of a collagen dressing. With regard to foam dressing (A6212), guidance is 
identified in LCD L33831. The wound care notes document foam filler. There was no foam dressing utilized 
LCD. With regard to ostomy skin barrier (A4406), guidance is identified in LCD L33828. There was no 
documentation of an ostomy. The wound care notes do not document the use of an ostomy skin barrier. 
Furthermore, for sterile water (A4216) and gauze pads (A6216) the Health Plan must follow Centers for 
Medicare & Medicaid Services (CMS) rules and guidance per LCD L33831. Per LCD L33831: The following 
are examples of wound care items which are NON-COVERED under the surgical dressing benefit because they 
DO NOT MEET the statutory definition of a dressing (not all-inclusive): Skin sealants or barriers (A6250); 
Wound cleansers (A6260) or irrigating solutions; Solutions used to moisten gauze (e.g., saline); Gauze or other 
dressings used to cleanse or debride a wound but not left on the wound; the requested items, which were used 
to clean the wound, are non-covered per the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the items have not been met. Therefore, we decided that the Plan does not have 
to pay for the sterile water, saline and/or dextrose, diluent/flush, 10 ml (A4216-A1 x50), gauze, non-
impregnated, non-sterile, pad size 16 sq. in. or less, without adhesive border, each dressing (A6216-A1 x200), 
ostomy skin barrier, pectin-based, paste, per ounce (A4406-A1 x8), collagen dressing, sterile, size 16 sq. in. or 
less, each (A6021-A1 x4), foam dressing, wound cover, sterile, pad size 16 sq. in. or less, with any size 
adhesive border, each dressing (A6212 x20) provided on November 3, 2022.