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The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules state that a gradient compression wrap is only covered when it is used as a primary or secondary
dressing over wounds that meet the statutory requirements for a qualifying wound (surgically created,
modified, or debrided). Claims for gradient compression wraps used without a qualifying wound or when used
for other non-qualifying conditions will be denied as statutorily non-covered, no benefit. Surgical dressings are
covered when a qualifying wound is present. A qualifying wound is defined as either of the following:
- A wound caused by, or treated by, a surgical procedure; or,
- After debridement of the wound, regardless of the debridement technique.
The surgical procedure or debridement must be performed by a treating practitioner or other healthcare
professional to the extent permissible under State law. Debridement of a wound may be any type of
debridement (examples given are not all-inclusive):
- Surgical (e.g., sharp instrument or laser)
- Mechanical (e.g., irrigation or wet-to-dry dressings)
- Chemical (e.g., topical application of enzymes) or
- Autolytic (e.g., application of occlusive dressings to an open wound).
Dressings used for mechanical debridement, to cover chemical debriding agents, or to cover wounds to allow
for autolytic debridement are covered although the debridement agents themselves are noncovered. Examples
(not all-inclusive) of clinical situations in which dressings are noncovered under the Surgical Dressings benefit
are:
- Drainage from a cutaneous fistula which has not been caused by or treated by a surgical procedure; or,
- A Stage 1 pressure ulcer; or,
- A first degree burn; or,
- Wounds caused by trauma which do not require surgical closure or debridement - e.g., skin tear or
abrasion; or,
- A venipuncture or arterial puncture site (e.g., blood sample) other than the site of an indwelling catheter
or needle.
A gradient compression stocking described by codes A6531 or A6532 or a non-elastic gradient compression
wrap described by code A6545 is only covered when it is used in the treatment of an open venous stasis ulcer
that meets the qualifying wound requirements described above. Codes A6531, A6532, and A6545 are noncovered
for the following conditions:
- Venous insufficiency without stasis ulcers;
- Prevention of stasis ulcers;
- Prevention of the reoccurrence of stasis ulcers that have healed;
- Treatment of lymphedema in the absence of ulcers.
In these situations, since there is no ulcer, the stockings/wraps do not meet the definition of a surgical dressing,
as there is no qualifying wound. Claims for these uses will be denied as non-covered, no benefit. You can find
these rules in Local Coverage Determination (LCD) Surgical Dressings (L33831) and the related Local
Coverage Article (LCA) Surgical Dressings Policy Article (A54563).
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.