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 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. 
 
The purpose of a Local Coverage Determination (LCD) is to provide information regarding reasonable and 
necessary criteria based on Social Security Act Section 1862(a)(1)(A) provisions. 
 
In addition to the reasonable and necessary criteria contained in this LCD there are other payment rules, 
which are discussed in the following documents, that must also be met prior to Medicare reimbursement: 
 
The LCD-related Standard Documentation Requirements Article, located at the bottom of this policy under the 
Related Local Coverage Documents section. The LCD-related Policy Article, located at the bottom of this 
policy under the Related Local Coverage Documents section. Refer to the Supplier Manual for additional 
information on documentation requirements. Refer to the durable medical equipment (DME) Medicare 
Administrative Contractor (MAC) web sites for additional bulletin articles and other publications related to this 
LCD. 
 
For the items addressed in this LCD, the reasonable and necessary criteria, based on Social Security Act 
Section 1862(a)(1)(A) provisions, are defined by the following coverage indications, limitations and/or medical 
necessity. 
 
The quantity of ostomy supplies needed by a beneficiary is determined primarily by the type of ostomy, its 
location, its construction, and the condition of the skin surface surrounding the stoma. There will be variation 
according to individual beneficiary need and their needs may vary over time. The table below lists the maximum number of items/units of service that are usually reasonable and necessary. The actual quantity 
needed for a particular beneficiary may be more or less than the amount listed depending on the factors that 
affect the frequency of barrier and pouch change. 
 
The explanation for use of a greater quantity of supplies than the amounts listed must be clearly documented in 
the beneficiarys medical record. If adequate documentation is not provided when requested, the excess 
quantities will be denied as not reasonable and necessary. 
 
You can find this information in Medicare's Local Coverage Determination (LCD): Ostomy Supplies (L33828). 
 
The rules say that a foam dressing (A6209, A6210, A6211, A6212, A6213, A6214, A6215) is a sterile, non-
linting, absorptive dressing which is made of open cell, medical grade expanded polymer. It has a non-adherent 
property over the wound site. Claims lines for A6212 billed without A1-A9 modifiers will be rejected as 
missing information. You can find this information in Medicare's Local Coverage Article: Surgical Dressings - 
Policy Article (A54563). 
 
The rules say that 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. 
 
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. 
 
Gauze, Non-Impregnated (A6216-A6221, A6402-A6404, A6407) 
Non-impregnated gauze dressing change is up to 3 times per day for a dressing without a border and once per 
day for a dressing with a border. It is usually not reasonable and necessary to stack more than 2 gauze pads on 
top of each other in any one area. 
 
You can find this information in Medicare's Local Coverage Determination (LCD): Surgical Dressings 
(L33831). 
 If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.