Appeal type: unknown
Decision: unknown

 
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 Medicare would expect that wound care may be necessary for the following types of 
wounds: 
 
1. Surgical wounds that must be left open to heal by secondary intention. 
2. Infected open wounds induced by trauma or surgery. 
3. Wounds with biofilm. 
4. Wounds associated with complicating autoimmune, metabolic, and vascular or pressure factors. 
5. Open or closed wounds complicated by necrotic tissue and/or eschar. 
 
You can find this rule in the Local Coverage Determination (LCD) - Wound Care (L35125) - Effective July 23, 
2020. 
 
The rules say that debridement may be indicated whenever necrotic tissue as well as cellular or proteinaceous 
debris is present on an open wound in order to keep the wound in an active state of healing. Debridement may 
also be indicated in cases of abnormal wound healing or repair. The routine application of a topical or local 
anesthetic does not elevate active wound care management to surgical debridement. Debridement may be 
categorized as selective or non-selective. Wound care selective debridement includes removal of specific, 
targeted areas of devitalized or necrotic tissue from a wound along the margin of viable tissue by sharp 
dissection utilizing scissors, scalpel, curettes, and/or tweezers/forceps. This procedure typically requires no 
anesthesia and generally has no or minimal associated bleeding. Wound care non-selective debridement may 
include: 
 
1. Mechanical Debridement: This type of debridement is the removal of necrotic tissue by cleansing, or 
application of a wetto-dry or dry-to-dry dressing technique. Wet-to-dry dressings should be used judiciously 
as maceration of surrounding tissue may hinder healing. Generally, dressing changes are not considered a 
skilled service. 
2. Enzymatic Debridement: Debridement with topical enzymes is used when the necrotic substances to be removed from a wound are protein, fiber and collagen. The manufacturers product insert contains indications, 
contraindications, precautions, dosage and administration guidelines; it is the clinicians responsibility to 
comply with those guidelines. 
3. Autolytic Debridement: This type of debridement is indicated where manageable amounts of necrotic tissue 
are present, and there is no infection. Autolytic debridement occurs when the enzymes that are naturally found 
in wound fluids are sequestered under synthetic dressings. 
4. Maggot / larvae therapy: Debridement with medical-grade maggots in wounds. 
 
You can find this rule in the Local Coverage Determination (LCD) - Wound Care (L35125) - Effective July 23, 
2020. 
 
The rules say that conditions that may require surgical debridement of large amounts of skin may include but 
are not limited to: rapidly spreading necrotizing process (sometimes seen with aggressive streptococcal 
infections), severe eczema, extensive skin trauma (including large abraded areas with ground-in dirt), or 
autoimmune skin diseases. Surgical debridement occurs only if material has been excised and is typically 
reported for the treatment of a wound to clear and maintain the site free of devitalized tissue including but not 
limited to necrosis, eschar, slough, infected tissue, biofilm, abnormal granulation tissue, etc., and should be 
accomplished to the margins of viable tissue. You can find this rule in the Local Coverage Determination 
(LCD) - Wound Care (L35125) - Effective July 23, 2020. 
 
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.