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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 chronic wounds are defined as wounds that do not respond to standard wound treatment for 
at least a 30 day period during organized comprehensive conservative therapy. For all wounds, documentation 
and a comprehensive treatment plan, before initiation of a specialized wound therapy product is required. For 
purposes of this LCD a failed response is defined as an ulcer or skin deficit that has failed to respond to 
documented appropriate wound-care measures, has increased in size or depth, or has not changed in baseline 
size or depth and has no indication that improvement is likely (such as granulation, epithelialization or progress 
towards closing). You can find this rule in the Local Coverage Determination (LCD) - Wound Application of 
Cellular and/or Tissue Based Products (CTPs), Lower Extremities (L36690). 
 
The rules say that Medicare covers application of cellular and/or tissue based products (CTPs)) to ulcers or 
wounds with failed response that are: 
 
1. Partial- or full-thickness ulcers, not involving tendon, muscle, joint capsule or exhibiting exposed bone or 
sinus tracts, with a clean granular base unless the CTP package label indicates the CTP is approved for use 
involving tendon, muscle, joint capsule or exhibiting exposed bone or sinus tracts, with a clean granular base ; 
2. Skin deficit at least 1.0 cm2 in size; 
3. Clean and free of necrotic debris or exudate; 
4. Have adequate circulation/oxygenation to support tissue growth/wound healing as evidenced by physical 
examination (e.g., Ankle-Brachial Index (ABI) of no less than 0.60, toe pressure > 30mm Hg); 
5. For diabetic foot ulcers, the patients medical record reflects a diagnosis of Type 1 or Type 2 Diabetes and 
also reflects medical management for this condition. 
 
You can find this rule in the Local Coverage Determination (LCD) - Wound Application of Cellular and/or 
Tissue Based Products (CTPs), Lower Extremities (L36690). 
 
The rules say that documentation (in the pre-service record) specifically addressing circumstances as to why 
the wound has failed to respond to standard wound care treatment of greater than 4 weeks and must reference 
specific interventions that have failed. Such record should include updated medication history, review of 
pertinent medical problems that may have occurred since the previous wound evaluation, and explanation of the planned skin replacement surgery with choice of CTP graft product. The procedure risks and complications 
should also be reviewed and documented. Documentation of smoking cessation counseling and cessation 
measures prescribed, if applicable, must also be documented in the patient's record. You can find this rule in 
the Local Coverage Determination (LCD) - Wound Application of Cellular and/or Tissue Based Products 
(CTPs), Lower Extremities (L36690). 
 
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.