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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 say that Hydrogel Dressing (A6231-A6233, A6242-A6248) 
 
Hydrogel dressings are covered when used on full thickness wounds (e.g., stage III or IV ulcers) with minimal 
or no exudate. Hydrogel dressings are not reasonable and necessary for stage II ulcers. Dressing change for 
hydrogel wound covers without adhesive border or hydrogel wound fillers is up to once per day. Dressing 
change for hydrogel wound covers with adhesive border is up to 3 times per week. 
 
The quantity of hydrogel filler used for each wound must not exceed the amount needed to line the surface of 
the wound. Additional amounts used to fill a cavity are not reasonable and necessary. Maximum utilization of 
code A6248 is 3 units (fluid ounces) per wound in 30 days. 
 
Use of more than one type of hydrogel dressing (filler, cover, or impregnated gauze) on the same wound at the 
same time is not reasonable and necessary. 
 
Tape (A4450, A4452) 
 
Tape is covered when needed to hold on a wound cover, elastic roll gauze or non-elastic roll gauze. Additional 
tape is not required when a wound cover with an adhesive border is used. Tape change is determined by the 
frequency of change of the wound cover. Quantities of tape submitted must reasonably reflect the size of the 
wound cover being secured. Utilization per dressing change for wound covers measuring: 
 
    16 square inches or less is up to 2 units 
    16 to 48 square inches, up to 3 units 
    Greater than 48 square inches, up to 4 units 
 
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) 
    Silicone gel sheets (A6025) 
    Topical antiseptics 
    Topical antibiotics 
    Enzymatic debriding agents 
    Gauze or other dressings used to cleanse or debride a wound but not left on the wound 
    First-aid type adhesive bandage (A6413) 
    Any item listed in the latest edition of the Orange Book (e.g., an antibiotic-impregnated dressing which 
requires a prescription 
    Gradient compression stockings (A6530, A6533, A6534, A6535, A6536, A6537, A6538, A6539, A6540, 
A6541, A6544, A6549) 
    Surgical stockings (A4490, A4495, A4500, A4510) 
    Non-elastic binder for an extremity (A4465) 
    Small adhesive bandages (e.g., Band-Aid or similar product) are not primarily used for the treatment of 
wounds addressed in the Surgical Dressings policy. 
 
These dressings are noncovered under the surgical dressing benefit. 
 
You can find this information in Medicare's Local Coverage Determination (LCD): Surgical Dressings 
(L33831) and Local Coverage Article: Surgical Dressings - Policy Article (A54563). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.