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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 the following are specific guidelines for individual product types. 
 
Collagen Dressing or Wound Filler (A6010, A6011, A6021-A6024) 
A collagen-based dressing or wound filler is covered for full thickness wounds (e.g., stage 3 or 4 ulcers), 
wounds with light to moderate exudate, or wounds that have stalled or have not progressed toward a healing 
goal. They can stay in place up to 7 days. Collagen based dressings are not covered for wounds with heavy 
exudate, third-degree burns, or when an active vasculitis is present. 
 
Foam Dressing or Wound Filler (A6209-A6215) 
Foam dressings are covered when used on full thickness wounds (e.g., stage 3 or 4 ulcers) with moderate to 
heavy exudate. Dressing changes for a foam wound cover used as a primary dressing is up to 3 times per week. 
When a foam wound cover is used as a secondary dressing for wounds with very heavy exudate, dressing 
change is up to 3 times per week. Dressing change frequency for foam wound fillers is up to once per day. 
 
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 
 
Light Compression Bandage (A6448-A6450), Moderate/High Compression Bandage (A6451, A6452), Self-
Adherent Bandage (A6453-A6455), Conforming Bandage (A6442-A6447), Padding Bandage (A6441) 
Compression bandages and multi-layer systems are only covered when they are used as a primary or secondary 
dressing over wound(s) that meet the statutory requirements for a qualifying wound (surgically created or 
modified, or debrided). 
 
Claims for compression bandages and multi-layer systems used without a qualifying wound or when used for 
other non-qualifying conditions will be denied as statutorily non-covered, no benefit. refer to the related policy 
article non-medical necessity coverage and payment rules for information about the statutory benefit 
requirements. 
 
Most compression bandages are reusable. Frequency of replacement would be no more than one per week 
unless they are part of a multi-layer compression bandage system. 
 
Conforming bandage dressing change is determined by the frequency of change of the selected underlying 
dressing. 
 
You can find these rules in the Local Coverage Determination (LCD) Surgical Dressings L33831. 
 
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.