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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 for any item to be covered by Medicare, it must 1) be eligible for a defined Medicare 
benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve 
the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and 
regulatory requirements. Information provided in this policy article relates to determinations other than those 
based on Social Security Act 1862(a)(1)(A) provisions (i.e. reasonable and necessary). 
Surgical Dressings are covered under the Surgical Dressings Benefit (Social Security Act 1861(s)(5)). The 
CMS Benefit Policy Manual (IOM 100-02), CH 15, 100 provides interpretive guidance to contractors for the 
implementation of this provision. The relevant part of the manual section establishes two separate benefit 
criteria: 
 The necessity for and definition of a qualifying wound; and, 
 The requirements necessary for any product to be classified as a surgical dressing for purposes of 
coverage under this benefit. 
In order for a beneficiarys item(s) to be eligible for reimbursement, all benefit requirements discussed below 
and the reasonable and necessary (R&N) requirements set out in the related Local Coverage Determination 
must be met. 
QUALIFYING WOUND 
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. 
Claims for surgical dressings used for clinical conditions other than the qualifying wounds as described above 
will be denied as statutorily non-covered, no benefit. 
QUALIFYING DRESSING REQUIREMENTS 
Products that are eligible to be classified as a surgical dressing are defined as: 
 Primary dressings - Therapeutic or protective coverings applied directly to wounds or lesions either on 
the skin or caused by an opening to the skin. 
 Secondary dressings - Materials that serve a therapeutic or protective function and that are needed to 
secure a primary dressing. Items such as adhesive tape, roll gauze, bandages, and disposable 
compression material are examples of secondary dressings. 
Some items, such as transparent film, may be used as a primary or secondary dressing. 
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. 
Claims for products that are not able to be used as a primary or secondary dressing on a qualifying wound of 
the skin or that are composed of materials that do not serve a therapeutic or protective function will be denied 
as statutorily non-covered, no benefit. 
You can find this rule at the Medicare Local Coverage Article (LCA) A54563: Surgical Dressings - Policy 
Article. 
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.