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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 application of a skin substitute graft for lower extremity DFU and VLU will be covered 
when the following conditions are met and documented as appropriate for the individual patient: 
 
Presence of neuropathic diabetic foot ulcer(s) having failed to respond to documented conservative wound-care 
measures of greater than four weeks. 

Presence of a chronic, non-infected venous stasis ulcer with failure to respond to documented conservative 
wound-care measures (outlined below) for greater than 4-6 weeks with documented compliance.  
For purposes of this LCD, conservative wound care measures include, but are not limited to: 
Comprehensive patient assessment (history, exam, ABI (Ankle-Brachial Index) & diagnostic test as indicated) 
and implemented treatment plan.  

For patient with DFU-assessment of type I vs. II Diabetes Mellitus and management history with attention to 
certain comorbidities (vascular disease, neuropathy, osteomyelitis); review of the current blood sugars/ 
HgbA1c, diet and nutritional status, activity level, physical exam that includes assessment of skin and wound, 
ABI (Ankle-Brachial Index), check of off-loading prosthetics or shoes for signs of abnormal wear. 

For patient with VLU- assessment of history (prior ulcers, thrombosis risks), physical exam (edema, skin 
changes), ABI (Ankle-Brachial Index), and duplex scan to confirm CEAP classification (Clinical-Etiology-
Anatomy-Pathophysiology (*CEAP) classification categorizes chronic venous disorders to facilitate 
communication between physicians, to serve as a basis for standardized reporting during scientific analysis of 
management alternatives, and to identify segments of venous incompetence amenable to vein ablation 
therapies.  
Implemented treatment plan as indicated. 
debridement 
pressure relief repositioning schedule, etc. for DFUs/VLUs; prior and on-going compression therapy (e.g., 
static compression includes compression hosiery (>20 mm HG) and compression bandages) for VLUs 
infection control 
management of exudate- maintenance of a moist environment (moist saline gauze, other classic dressings, 
bioactive dressing, etc.). (For indications of negative pressure wound therapy (NPWT) see DME MAC LCD Negative Pressure Wound Therapy Pumps (L5008)) 
Patient is a nonsmoker, or has refrained from smoking for at least 6 weeks prior to planned skin replacement 
surgery, or has received counseling on the effects of smoking on surgical outcomes and treatment for smoking 
cessation. 
Applied to ulcers that have failed to respond to documented conservative wound-care measures. "Failed 
response" is defined as an ulcer that has increased in size or depth, or no change in baseline size or depth or no 
sign of improvement or indication that improvement is likely (such as granulation, epithelialization or progress 
towards closing). Documentation of response requires measurements of the initial ulcer, measurements at the 
completion of at least four weeks DFU (4-6 weeks for VLU) of conservative wound-care measures and 
measurements immediately prior to placement of the skin substitute graft. For VLUs, completion of 
conservative wound-care measures must include 4-6 weeks and on-going compression therapy. 
A skin replacement surgery is considered an advanced treatment modality (not a conservative wound care 
measure). Pre-service record specifically addresses 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 based on the prior wound evaluation. Such record should include updated medication history, review of 
pertinent medical problems that may have arisen since the previous wound evaluation, and explanation of the 
planned skin replacement surgery with choice of skin substitute graft product. The procedure risks and 
complications should also be reviewed and documented. 
 
You can find this information in the Local Coverage Determination (LCD) Application of Skin Substitute 
Grafts for Treatment of DFU and VLU of Lower Extremities L36377. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.