Surgical Dressing/Wound Care
PRODUCT COVERAGE CRITERIA CHART
ITEM #
ITEM DESCRIPTION
MANUFAC.
HCPCS
MAX QTY
ALLOWED
DEBRIDING
AGENT
QTY
UOM
ALGINATE DRESSINGS - Stages III or IV; moderate to heavy exudate, full thickness wounds; wound cannot have dry eschar/scab.
Necrotic tissue may be present. Cannot use Hydrogel at same time.
16 SQ IN. OR LESS
MSC7022
529938
MSC9422
529967
MSC7044
529937
MAXORB XTRA DRSG 2X2
RESTORE CALCIUM ALGINATE 2X2
MAXORB XTRA AG DRSG 2X2
RESTORE CALCIUM ALGINATE SILVER 2X2
MAXORB XTRA DRSG 4X4
RESTORE CALCIUM ALGINATE 4X4
MEDLINE
HOLLISTER
MEDLINE
HOLLISTER
MEDLINE
HOLLISTER
A6196
A6196
A6196
A6196
A6196
A6196
1/DAY
1/DAY
1/DAY
1/DAY
1/DAY
1/DAY
YES
YES
YES
YES
YES
YES
10
10
10
10
10
10
BX
BX
BX
BX
BX
BX
MORE THAN 16 SQ IN. BUT LESS THAN OR EQUAL TO 48 SQ IN.
529968
RESTORE CALCIUM ALGINATE SILVER 4X4.75
MSC9445
MAXORB XTRA AG DRSG 4X4.75
529939
RESTORE CALCIUM ALGINATE 4X8
MSC7048
MAXORB XTRA DRSG 4X8
HOLLISTER
MEDLINE
HOLLISTER
MEDLINE
A6197
A6197
A6197
A6197
1/DAY
1/DAY
1/DAY
1/DAY
YES
YES
YES
YES
10
10
5
5
BX
BX
BX
BX
WOUND FILLER/ROPE
MSC7012
MAXORB CMC/ALGINATE DRESSING 12" ROPE
529940
RESTORE CALCIUM ALGINATE ROPE 12"
MSC9412
MAXORB AG ROPE 12"
529969
RESTORE CALCIUM ALGINATE SILVER ROPE
MEDLINE
HOLLISTER
MEDLINE
HOLLISTER
A6199
A6199
A6199
A6199
1/DAY
1/DAY
1/DAY
1/DAY
YES
YES
YES
YES
5
5
5
5
BX
BX
BX
BX
ANTIMICROBIAL DRESSINGS - S
tages III or IV; moderate to heavy exudate, full thickness wounds; wound. This is a primary dressing. Cannot use
Hydrogel at same time.
WOUND FILLER, DRY FORM, PER GRAM
MSC9360EP
SILVASORB 6 GM CAVITY DRSG
MEDLINE
A6262
1/DAY
POSSIBLE
5
BX
COLLAGEN DRESSINGS - Stages III or IV; light to moderate exudate. Should not be used on dry wounds.
Wounds should have <25% necrotic tissue.
16 SQ IN. OR LESS
MSC8522
MSC8722
MSC861X8EP
PG004
MSC8622
MEDLINE
MEDLINE
MEDLINE
J&J
MEDLINE
A6021
A6021
A6021
A6021
A6021
1/DAY
1/DAY
1/DAY
1/DAY
1/DAY
YES
YES
YES
YES
YES
10
10
10
10
10
BX
BX
BX
BX
BX
MORE THAN 16 SQ IN. BUT LESS THAN OR EQUAL TO 48 SQ IN.
MSC8544
PURACOL COLLAGEN 4 X 4.25
MSC8644
PURACOL PLUS COLLAGEN 4.25X4.5 (PAD 1.3X1.6)
MEDLINE
MEDLINE
A6021
A6022
1/DAY
1/DAY
YES
YES
10
BX
YES
YES
10
BX
MORE THAN 48 SQ IN.
MSC8588H
PURACOL COLLAGEN, 8X8
MSC8488H
PURACOL COLLAGEN, AG SILVER 8X8
MEDLINE
MEDLINE
A6023
A6023
1/DAY
1/DAY
YES
YES
50
50
CS
CS
MSC8744
MA028
PURACOL COLLAGEN DRSG 2 X 2
PURACOL PLUS AG SILVER 2X2.25
PURACOL PLUS COLLAGEN ROPE 8"
PROMOGRAN WND DRSG 4.34"
PURACOL PLUS COLLAGEN 2X2
PURACOL PLUS AG SILVER 4.25X4.5
PRISMA MATRIX 4.34” HEXAGON COLLAGEN
MEDLINE
J&J
A6022
A6021
1/DAY
1/DAY
COMPOSITE/COVER DRESSINGS - One wound cover allowed per dressing change. Cannot bill tape seperately.
Very absorptive & should NOT be used with hydrogel.
16 SQ IN. OR LESS - BORDERED
MSC3044
STRATASORB 4X4 COMP ISLAND DRSG (PAD 2.5X2)
MSC3066
STRATASORB COMP ISL DRSG 6X6 (PAD 4X4)
MEDLINE
MEDLINE
A6203
A6203
3/WEEK
3/WEEK
YES
YES
10
10
BX
BX
MORE THAN 16 SQ IN. BUT LESS THAN OR EQUAL TO 48 SQ IN. - BORDERED
MSC3068
STRATASORB 6X8 COMP ISLAND DRSG (PAD 4X6)
MEDLINE
A6204
3/WEEK
YES
10
BX
Appendix G PAGE 1
Surgical Dressing/Wound Care
PRODUCT COVERAGE CRITERIA CHART
ITEM #
ITEM DESCRIPTION
MANUFAC.
HCPCS
MAX QTY
ALLOWED
DEBRIDING
AGENT
QTY
UOM
COMPRESSION BANDAGES - Most compression bandages are reusable, frequency of replacement is 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 the
change of the underlying dressing.
WIDTH LESS THAN 3 IN.
MDS087003LF
MDS087004LF
GAUZE MATRIX 3" X 5 YD VELCRO
GAUZE MATRIX 4" X 5 YD VELCRO
MEDLINE
MEDLINE
A6449
A6449
1/WEEK
1/WEEK
NO
NO
10
10
BX
BX
WIDTH GREATER THAN OR EQUAL TO 5 IN.
MDS087006LF GAUZE MATRIX 6" X 5 YD VELCRO
MEDLINE
A6450
1/WEEK
NO
10
BX
NO
1
KT
BANDAGE SYSTEM
A6441/
A6449/
MSC4400
BANDAGE 4"X5 YD FOUR FLEX *COMPONENTS*
MEDLINE
1/WEEK
A6452/
A6454
CONTACT LAYERS - Only used as a primary dressing; used to line the entire wound. Not to be changed with each dressing.
16 SQ IN. OR LESS
RESTORE CONTACT LAYER W/ TRIACT
TECHNOLOGY 2X2
MSC1723EP
VERSATEL CONTACT LAYER DRSG 2X3
MORE THAN 16 SQ IN. BUT LESS THAN OR EQUAL TO 48 SQ IN.
MSC1747EPH
VERSATEL CONTACT LAYER 4X7
509338
RESTORE CONTACT LAYER W/TRIACT TECH 4X5
509339
RESTORE CONTACT LAYER W/TRIACT TECH 6X8
MSC1747
VERSATEL CONTACT LAYER 4 X 7
MORE THAN 48 SQ IN.
MSC1747EPH
VERSATEL CONTACT LAYER 4X7
509379
RESTORE CONTACT LAYER W/ TRIACT TECH 8"X12"
506487
HOLLISTER
A6206
1/WEEK
NO
10
BX
MEDLINE
A6206
1/WEEK
NO
10
BX
MEDLINE
HOLLISTER
HOLLISTER
MEDLINE
A6207
A6207
A6207
A6207
1/WEEK
1/WEEK
1/WEEK
1/WEEK
NO
NO
NO
NO
10
10
10
10
BX
BX
BX
BX
MEDLINE
HOLLISTER
A6207
A6208
1/WEEK
1/WEEK
NO
NO
10
10
BX
BX
FOAM DRESSINGS - BORDERED - Stage III or IV, moderate to heavy drainage, dressing should be 2” larger than perimeter of the wound.
For short term usage.
16 SQ IN. OR LESS - BORDERED
MSC2424H
OPTIFOAM 2X4.5 (PAD 1.5X2)
MSC1044
OPTIFOAM DRSG 4X4 W/BORDER ADH (PAD 2.5X2.5)
509348
RESTORE FOAM BORDER TRIAL 6X6 (PAD 4X4)
509387
RESTORE FOAM BORDER TRIACT ADV 4X4 (PAD 2X2)
509387
RESTORE FOAM BORDER TRIACT ADV 4X4 (PAD 2X2)
MSC9604EP
OPTIFOAM 4X4 ADH AG DRSG
509388
RESTORE FOAM BORDER TRIACT ADV 6X6 (PAD 4X4)
MSC1065EP
OPTIFOAM 6.1X5.6 SACRUM DRSG
203
POLYMEM 2X2 FOAM
7042
POLYMEM ISL DRSG 2X4 STRIP
295200
MEPILEX BORDER DRSG 3X3
MSC9604
OPTIFOAM 4X4 ADH AG DRSG
529304
RESTORE FOAM, 4X4 BORDER HYDRO-SHIELD
MEDLINE
MEDLINE
HOLLISTER
HOLLISTER
HOLLISTER
MEDLINE
HOLLISTER
MEDLINE
MEDLINE
MEDLINE
MEDLINE
MEDLINE
HOLLISTER
A6212
A6212
A6212
A6212
A6212
A6212
A6212
A6212
A6212
A6212
A6212
A6212
A6212
3/WEEK
3/WEEK
3/WEEK
3/WEEK
3/WEEK
3/WEEK
3/WEEK
3/WEEK
3/WEEK
3/WEEK
3/WEEK
3/WEEK
3/WEEK
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
1
10
10
10
10
10
10
10
100
100
5
10
10
EA
BX
BX
BX
BX
BX
BX
BX
CS
CS
BX
BX
BX
MORE THAN 16 SQ IN. BUT LESS THAN OR EQUAL TO 48 SQ IN. - BORDERED
MSC1066EP
OPTIFOAM DRSG 6X6 FOAM ADH
MEDLINE
529305
RESTORE HYDROSHIELD BORDER FOAM 6X6
HOLLISTER
509389
RESTORE FOAM BORDER TRIACT ADV 6X8
HOLLISTER
509390
RESTORE FOAM BORDER TRIACT ADVANCED 8X8
HOLLISTER
A6213
A6213
A6213
A6213
3/WEEK
3/WEEK
3/WEEK
3/WEEK
YES
YES
YES
YES
10
10
10
10
BX
BX
BX
BX
10
10
BX
BX
FOAM DRESSINGS - NON-BORDERED - Stage III or IV, moderate to heavy drainage, dressing should be 2” larger than perimeter of the wound.
For short term usage.
16 SQ IN. OR LESS - NO BORDER
509380
RESTORE FOAM NON-BORDER 2.5 X 2.5 TRIACT ADV
509393
RESTORE FOAM TRIACT ADV LITE 2.5X2.5
HOLLISTER
HOLLISTER
A6209
A6209
3/WEEK
3/WEEK
YES
YES
Appendix G PAGE 2
Surgical Dressing/Wound Care
PRODUCT COVERAGE CRITERIA CHART
MAX QTY
ALLOWED
DEBRIDING
AGENT
QTY
UOM
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
10
10
10
10
10
10
10
10
10
10
BX
BX
BX
BX
BX
BX
BX
BX
BX
BX
A6210
A6210
A6210
A6210
A6210
A6210
A6210
A6210
A6210
A6210
A6210
3/WEEK
3/WEEK
3/WEEK
3/WEEK
3/WEEK
3/WEEK
3/WEEK
3/WEEK
3/WEEK
3/WEEK
3/WEEK
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
10
10
10
10
10
10
10
10
10
10
5
BX
BX
BX
BX
BX
BX
BX
BX
BX
BX
BX
A6211
3/WEEK
YES
10
BX
ITEM #
ITEM DESCRIPTION
MANUFAC.
HCPCS
509380
509343
MSC1133F
MSC1244
MSC9614
509381
519904
509381
HB2214
509345
RESTORE FOAM NON-BORDER 2.5 X 2.5 TRIACT ADV
RESOTRE NON ADH FOAM DRESSING 4X4
OPTIFOAM 3X3 PAD
OPTIFOAM 4X4
OPTIFOAM DRSG 4X4 NON ADH AG
RESTORE FOAM NONBORDER TRIACT ADV 4X4
RESTORE ODOR ABSORBENT DRESSING 4X4
RESTORE FOAM NONBORDER TRIACT ADV 4X4
HYDROFERA BLUE 2X2
RESTORE FOAM DRSG SILVER NON-ADH TRIACT 4X4
HOLLISTER
HOLLISTER
MEDLINE
MEDLINE
MEDLINE
HOLLISTER
HOLLISTER
HOLLISTER
HOLLISTER
HOLLISTER
A6209
A6209
A6209
A6209
A6209
A6209
A6209
A6209
A6209
A6209
MORE THAN 16 SQ IN. BUT LESS THAN OR EQUAL TO 48 SQ IN. - NO BORDER
MSC1145
OPTIFOAM 4X5 PAD
MEDLINE
509394
RESTORE LITE FOAM 4X5
HOLLISTER
509384
RESTORE FOAM HEEL DRESSING 4.7X7.5
HOLLISTER
MSC1266
OPTIFOAM 6X6 NADH
MEDLINE
509395
RESTORE LITE FOAM 6X6
HOLLISTER
509382
RESTORE FOAM NONBRDR - TRIACT ADV 6X6
HOLLISTER
509382
RESTORE FOAM NONBRDR - TRIACT ADV 6X6
HOLLISTER
509396
RESTORE LITE FOAM NON BRDR TRIACT ADV 6X8
HOLLISTER
509346
RESTORE FOAM DRSG SILVER NON-ADH TRIACT 6X8 HOLLISTER
509382
RESTORE FOAM NONBRDR - TRIACT ADV 6X6
HOLLISTER
MSC1200EP
OPTIFOAM DRSG NON ADH HEEL
MEDLINE
MORE THAN 48 SQ IN. - NO BORDER
519906
RESTORE ODO ABSORBENT DRESSING 6X10
HOLLISTER
3/WEEK
3/WEEK
3/WEEK
3/WEEK
3/WEEK
3/WEEK
3/WEEK
3/WEEK
3/WEEK
3/WEEK
GAUZE - IMPREGNATED - No more than 2 gauze pads on one wound per change. Always used as a primary dressing; requires a secondary dressing on top.
16 SQ IN. OR LESS - NO BORDER
CUR253180
XEROFORM 1X8 ST GAUZE DRSG
CUR251180
GAUZE, PETROLATUM, 1X8
CUR253220
XEROFORM 2 X 2 GAUZE ST
NON250330
IMPREGNATED OIL EMULSION 3X3
CUR253440
XEROFORM 4 X 4 GAUZE ST
NON250381
OIL EMULSION NADH DRESSING 3X8
CUR251390
PETROLATUM GAUZE DRSG 3 X 9 ST
CUR253590
XEROFORM 5X9 ST GAUZE IMP
285780
MESALT 6X6 IMP GAUZE
CUR250317
GAUZE DRESSING ADAPTIC OIL 3X16
MORE THAN 48 SQ IN. - NO BORDER
CUR251318
PETROLATUM GAUZE DRSG 3 X 18 ST
CUR251636
PETROLATUM GAUZE DRSG 6 X 36 ST
MEDLINE
MEDLINE
MEDLINE
MEDLINE
MEDLINE
MEDLINE
MEDLINE
MEDLINE
MOLNLYCKE
MEDLINE
A6222
A6222
A6222
A6222
A6222
A6223
A6223
A6223
A6223
A6223
1/DAY
1/DAY
1/DAY
1/DAY
1/DAY
1/DAY
1/DAY
1/DAY
1/DAY
1/DAY
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
50
50
25
50
25
25
25
25
25
25
BX
BX
BX
BX
BX
BX
BX
BX
BX
BX
MEDLINE
MEDLINE
A6224
A6224
N/A
N/A
N/A
N/A
12
12
BX
BX
GAUZE - HYDROGEL - IMPREGNATED - S
tage III or IV; full thickness wounds, little or no drainage; cannot use with alginate dressings; do not use with
hydrogel wound filler at any time; Stage II- only if the wound is in the sacral/ coccyx area.
16 SQ IN. OR LESS
MSC6022
529972
MSC6144
MSC6044
SKINTEGRITY 2X2 HYDROGEL GAUZE
RESTORE 4X4 HYDROGEL
GAUZE, HYDROGEL, SKINTEGRITY 4x4
SKINTEGRITY 4X4 HYDROGEL GAUZE
MEDLINE
HOLLISTER
MEDLINE
MEDLINE
A6231
A6231
A6231
A6231
1/DAY
1/DAY
1/DAY
1/DAY
YES
YES
YES
YES
50
15
60
30
Appendix G PAGE 3
CS
BX
CS
CS
Surgical Dressing/Wound Care
PRODUCT COVERAGE CRITERIA CHART
ITEM #
ITEM DESCRIPTION
MANUFAC.
HCPCS
MAX QTY
ALLOWED
DEBRIDING
AGENT
QTY
UOM
GAUZE - ZINC - IMPREGNATED - The carrier assigned CMS type of service which describes the particular kind(s) of service represented by the
procedure code.
WIDTH GREATER THAN OR EQUAL TO 3 IN. AND LESS THAN 5 IN.
NONUNNA3
UNNABOOT 3" X 10YD W/CALAMINE
NONUNNA13
UNNABOOT 3" X 10YD W/O CALAMINE
NONUNNA4
UNNABOOT 4"X10YD W/CALAMINE
NONUNNA14
UNNABOOT 4" X 10YD W/O CALAMINE
MEDLINE
MEDLINE
MEDLINE
MEDLINE
A6456
A6456
A6456
A6456
1/WEEK
1/WEEK
1/WEEK
1/WEEK
NO
NO
NO
NO
12
12
12
12
CS
CS
CS
CS
GAUZE - NON-IMPREGNATED - No more than 2 gauze pads on one wound per change.
16 SQ IN. OR LESS - BORDERED
MSC3222
GAUZE BORDERED 2X2 (PAD 1X1)
MSC3244
GAUZE BRDR 4X4 (PAD 2.5X2.5)
MEDLINE
MEDLINE
A6219
A6219
2/DAY
2/DAY
NO
NO
15
15
BX
BX
MORE THAN 16 SQ IN. BUT LESS THAN OR EQUAL TO 48 SQ IN. - BORDERED
MSC32410
GAUZE, BORDERED, 4X10
MEDLINE
MSC3266
GAUZE BRDR 6X6
MEDLINE
A6220
A6220
2/DAY
2/DAY
NO
NO
15
15
BX
BX
GAUZE - NON-IMPREGNATED - NON-ADHERENT - Stage II, III, or IV, light to moderate drainage; unless covered by secondary dressing then can be
used on heavily draining wound.
16 SQ IN. OR LESS THAN OR EQUAL TO 48 SQ IN. - NO BORDER
PRM2208
GAUZE 2X2 8 PLY STERILE
1961
GAUZE TELFA 2X3 NADH ST
PRM3312
GAUZE 3X3 12PLY STERILE
NON21424
GAUZE 4X4 12 PLY ST PK/2
NON21448
GAUZE 4X4 8PLY ST AML GAUZE SPONGE
NON256000
DRAIN SPONGE AVANT 4X4 6 PLY ST
PRM4412
GAUZE 4X4 SPONGE 12 PLY ST 2/PK
PRM2208H
CARING, STERILE, LF, 8 PLY, 2X2
PRM4408H
CARING, STERILE, LF, 8 PLY, 4X4
MEDLINE
KENDALL
MEDLINE
MEDLINE
MEDLINE
MEDLINE
MEDLINE
MEDLINE
MEDLINE
A6402
A6402
A6402
A6402
A6402
A6402
A6402
A6216
A6216
6/DAY
6/DAY
6/DAY
6/DAY
6/DAY
6/DAY
6/DAY
6/DAY
6/DAY
NO
NO
NO
NO
NO
NO
NO
NO
NO
100
100
80
50
100
50
50
100
1
BX
BX
BX
BX
BX
BX
BX
BX
BX
16 SQ IN. OR LESS - NO BORDER - STERILE
NON25444
GAUZE 4X4 4 PLY NS
NON25208
GAUZE 2X2 8 PLY NS
NON25408
GAUZE 4X4 NS SPONGE
MEDLINE
MEDLINE
MEDLINE
A6216
A6216
A6216
6/DAY
6/DAY
6/DAY
NO
NO
NO
200
200
200
BG
PK
PK
MORE THAN 16 SQ IN. BUT LESS THAN OR EQUAL TO 48 SQ IN. - NO BORDER
NON21842
GAUZE 8X4 12 PLY SPONGE ST
MEDLINE
NON25852
GAUZE 6X6.75 SPONGE FLUFF
MEDLINE
1238
TELFA NADH 3X8 ST GAUZE
KENDALL
A6403
A6403
A6403
6/DAY
6/DAY
6/DAY
NO
NO
NO
50
40
50
BX
BX
BX
A6266
A6266
A6266
A6266
A6266
A6266
1 YD/DAY
1 YD/DAY
1 YD/DAY
1 YD/DAY
1 YD/DAY
1 YD/DAY
YES
YES
YES
YES
YES
YES
12
12
12
12
100
12
CS
CS
CS
BX
CS
CS
GAUZE - PACKING STRIPS - IMPREGNATED - Do not use with a dressing w/ an adhesive border.
ANY WIDTH
NON256145
NON256015
NON256025H
529973
3332COV
NON256125
PKG STRIP 1/4"X5YD IODOFORM
PKG STRIP 1"X5YD IODOFORM
PKG STRIP 2"X5YD IODOFORM
RESTORE HYDROGEL IMP GAUZE STRIP 2"X3/5" YD
GAUZE 4.5X4 1YD KERLIX AMB POUCH
PKG STRIP 1/2"X5YDS IODOFORM GAUZE
MEDLINE
MEDLINE
MEDLINE
HOLLISTER
KENDALL
MEDLINE
GAUZE - PACKING STRIPS - NON-IMPREGNATED - D
ressing materials which is placed into open wounds to eliminate dead spaces, absorb exudate,
or maintain a moist surface.
UP TO 2 INCHES IN WIDTH
NON255145
PKG STRIP GAUZE 1/4" X 5 YD
NON255125
PK STRIP 1/2"X5YD PLAIN ST
NON255015
PKG STRIP 1"X5YD ST
NON255025
PKG STRIP 2"X5YD STERILE
MEDLINE
MEDLINE
MEDLINE
MEDLINE
A6407
A6407
A6407
A6407
1 YD/DAY
1 YD/DAY
1 YD/DAY
1 YD/DAY
NO
NO
NO
NO
12
12
12
12
Appendix G PAGE 4
CS
CS
CS
CS
Surgical Dressing/Wound Care
PRODUCT COVERAGE CRITERIA CHART
ITEM #
ITEM DESCRIPTION
MANUFAC.
HCPCS
MAX QTY
ALLOWED
DEBRIDING
AGENT
QTY
UOM
GAUZES - ROLL - STERILE - Conforming bandage dressing change is determined by the frequency of the change of the underlying dressing.
WIDTH LESS THAN 3 IN.
NON25496
BANDAGE 2"X75" NS GAUZE SOF-FORM
WIDTH GREATER THAN OR EQUAL TO 3 IN. AND LESS THAN 5 IN.
NON25497
GAUZE 3X75 SOF-FOAM ST
NON25498
GAUZE 4X75 SOF-FORM ST
NON25865
GAUZE 4.5"X4.1YD ST STREH
WIDTH GREATER THAN OR EQUAL TO 5 IN.
NON25865
GAUZE 4.5"X4.1YD ST STREH
NON25499
BANDAGE 6X80 ST GAUZE SOF-FORM
MEDLINE
A6445
1 ROLL/DAY
NO
12
BX
MEDLINE
MEDLINE
MEDLINE
A6446
A6446
A6446
1 ROLL/DAY
1 ROLL/DAY
1 ROLL/DAY
NO
NO
NO
96
96
100
CS
CS
CS
MEDLINE
MEDLINE
A6447
A6447
1 ROLL/DAY
1 ROLL/DAY
NO
NO
100
48
CS
CS
GAUZE - SPONGES - NON-IMPREGNATED - Stage II, III, or IV, light to moderate drainage; unless covered by secondary dressing then can be used on
heavily draining wound.
16 SQ IN. OR LESS - NO BORDER
PRM2208H
CARING, STERILE, LF, 8-PLY, 2X2
PRM4408H
CARING, STERILE, LF, 8-PLY, 4X4
MEDLINE
MEDLINE
A6402
A6402
6/DAY
6/DAY
NO
NO
100
1
BX
PK
HYDROCOLLOID DRESSINGS - Stages II, III, or IV, light to moderate drainage, dressing should be 2” larger than perimeter of wound. No more than one
Hydrocolloid can be used on a wound.
16 SQ IN. OR LESS - NO BORDER
MSC5522
EXUDERM ODORSHIELD HYDROPOLYMER 2X2
MSC5570
EXUDERM 4X3.6 ORDERSHIELD DRSG
MSC5544
EXUDERM ODORSHIELD HYDROPOLYMER 4X4
519921
RESTORE XTHIN HYDROCOLLOID 4X4
519930
RESTORE HYDROCOLLOID 4X4
519953
RESTORE HYDROCOLLOID 4X4
MSC5100
EXUDERM 4X4 THIN HYDROCOLLOID
519956
RESTORE HYDROCOLLOID W/ TAPER EDGE 4X4
MEDLINE
MEDLINE
MEDLINE
HOLLISTER
HOLLISTER
HOLLISTER
MEDLINE
HOLLISTER
A6234
A6234
A6234
A6234
A6234
A6234
A6234
A6234
3/WEEK
3/WEEK
3/WEEK
3/WEEK
3/WEEK
3/WEEK
3/WEEK
3/WEEK
YES
YES
YES
YES
YES
YES
YES
YES
10
10
10
5
5
5
10
5
BX
BX
BX
BX
BX
BX
BX
BX
MORE THAN 16 SQ IN. BUT LESS THAN OR EQUAL TO 48 SQ IN. - NO BORDER
MSC5566
EXUDERM 6X6 ODOR SHIELD DRSG
MEDLINE
519963
RESTORE HYDROCOLLOID W/ TAPERED EDGE 6X6
HOLLISTER
MSC5575
EXUDERM 6.4X6.5 ODORSHIELD DRSG
MEDLINE
519954
RESTORE DRSG 6X8 HYDROCOLLOID
HOLLISTER
519923
RESTORE XTHIN HYDROCOLLOID 6X8
HOLLISTER
519959
RESTORE HYDROCOLLOID TRIANGLE 17 SQ IN
HOLLISTER
519965
RESTORE HYDROCOLLOID TRIANGLE 26.5 SQ IN
HOLLISTER
A6235
A6235
A6235
A6235
A6235
A6235
A6235
3/WEEK
3/WEEK
3/WEEK
3/WEEK
3/WEEK
3/WEEK
3/WEEK
YES
YES
YES
YES
YES
YES
YES
5
5
5
3
3
5
5
BX
BX
BX
BX
BX
BX
BX
MORE THAN 48 SQ IN. - NO BORDER
MSC5588
EXUDERM ODORSHIELD HYDROPOLYMER 8X8
519958
RESTORE HYDROCOLLOID W/TAPER EDGE 8X8
MEDLINE
HOLLISTER
A6236
A6236
3/WEEK
3/WEEK
YES
YES
5
3
BX
BX
16 SQ IN. OR LESS - BORDERED
509372
RESTORE TRIO ADHESIVE 3X3
509373
RESTORE TRIO ADHESIVE 4X5
HOLLISTER
HOLLISTER
A6237
A6237
3/WEEK
3/WEEK
YES
YES
10
10
BX
BX
MORE THAN 16 SQ IN. BUT LESS THAN OR EQUAL TO 48 SQ IN. - BORDERED
509374
RESTORE TRIO ADHESIVE 6X8
HOLLISTER
A6238
3/WEEK
YES
10
BX
A6240
A6240
A6250
3 OZ/MONTH
3 OZ/MONTH
N/A
YES
YES
N/A
10
1
BX
BX
HYDROCOLLOID DRESSINGS - WOUND FILLER - Stage III or IV; light to moderate drainage; requires a secondary dressing. Only one Hydrocolloid
can be used on a wound.
PASTE OR GEL PER OUNCE
31805
31815
MEDIHONEY GEL .5 OZ
MEDIHONEY GEL 1.5 OZ
MEDIHONEY PASTE PRODUCTS - NOT COVERED
Appendix G PAGE 5
Surgical Dressing/Wound Care
PRODUCT COVERAGE CRITERIA CHART
ITEM #
ITEM DESCRIPTION
MANUFAC.
HCPCS
MAX QTY
ALLOWED
DEBRIDING
AGENT
QTY
UOM
HYDROGEL DRESSINGS - S
tage III or IV; full thickness wounds, little or no drainage; cannot use with alginate dressings; do not use with hydrogel
wound filler at any time; Stage II- only if the wound is in the sacral/coccyx area.
16 SQ IN. OR LESS - NO BORDER
MSC8403
TENDERWET DRESSING 3X3
MSC8402
TENDERWET ACTIVE CAVITY 2.2" ROUND
MSC9340EP
SILVASORB 4X4 ANTIMICROB PERF
MEDLINE
MEDLINE
MEDLINE
A6242
A6242
A6242
1/DAY
1/DAY
1/DAY
YES
YES
YES
7
7
5
BX
BX
BX
MORE THAN 16 SQ IN. BUT LESS THAN OR EQUAL TO 48 SQ IN. - NO BORDER
MSC8405
TENDERWET DRESSING RECTANGULAR 4X5
MEDLINE
A6243
1/DAY
YES
7
BX
12
12
12
30
CS
CS
CS
CS
HYDROGEL TUBES - Stage III or IV; little or no drainage. Used to line wound, not to fill deep openings. Requires secondary dressing.
GEL - PER FLUID OZ.
MSC9303EPH
529974
MSC6104
MSC6102H
SILVASORB HYDROGEL 3 OZ
RESTORE HYDROGEL AMORPH 3 OZ TUBE
SKINTEGRITY HYDROGEL 4 OZ
SKINTEGRITY HYDROGEL 1 OZ TUBE
MEDLINE
HOLLISTER
MEDLINE
MEDLINE
A6248
A6248
A6248
A6248
3 OZ/MONTH
3 OZ/MONTH
3 OZ/MONTH
3 OZ/MONTH
YES
YES
YES
YES
SELF-ADHERENT BANDAGES - Covered when they are used to hold wound cover dressings in place over any wound type or when used as part of
a multi layer compression bandage system used in the treatment of a venous stasis ulcer.
WIDTH LESS THAN 3 IN.
MDS089002
COFLEX, LF2 FOAM, 2X5
WIDTH GREATER THAN OR EQUAL TO 3 IN. BUT LESS THAN 5 IN.
MDS089003
COFLEX 3"X5YD LFZ FOAM BANDAGE
MDS086004
BANDAGE 4"X5YD COFLEX TAN MED LATEX
MEDLINE
A6453
1/WEEK
NO
36
CS
MEDLINE
MEDLINE
A6454
A6454
1/WEEK
1/WEEK
NO
NO
24
18
CS
CS
SPECIALTY ABSORPTIVE DRESSING - NO BORDER - Stage III or IV, moderate or heavy exudate wound. Primary or w/o secondary dressing.
16 SQ IN. OR LESS
MSC6444EP
OPTILOCK DRSG NON ADH 4X4
MORE THAN 16 SQ IN. BUT LESS THAN 48 SQ IN.
MSC6455EP
OPTILOCK DRSG NON ADH 5X5.5
PRM21450
ABD PAD CARING 5X9
MEDLINE
A6251
1/DAY
NO
10
BX
MEDLINE
MEDLINE
A6252
A6252
1/DAY
1/DAY
NO
NO
10
25
BX
BX
1/DAY
1/DAY
1/DAY
NO
NO
NO
10
18
1
BX
BX
EA
MORE THAN 48 SQ IN.
MSC64610EP
OPTILOCK DRSG NON ADH 6.5X10
MEDLINE
A6253
NON21454
ABD PAD 8X10 ST
MEDLINE
A6253
SMITH & NEPHEW A6253
5999018
EXUDRY15X18 SPECIAL ABS DRSG
TAPE - U
sed to hold elastic roll gauze or non elastic roll gauze or wound cover without an adhesive border.
Not covered when used with an elastic border gauze unless medical necessity is documented.
NON-WATERPROOF
MSC4002
MSC4004
MSC4006
NON260201
NON260202
NON260003
WATERPROOF
HY105BLF
NON260501H
NON260502H
NON260503H
MSC4104
TAPE 2"X10YD RETENTION MEDFIX
TAPE 4"X11YD RETENTION MEDFIX
TAPE 6"X11YD RETENTION MEDFIX
TAPE 1"X10YD TRANSPARENT CURAD
TAPE TRANSPARENT ADHESIVE CURAD 2" X 10 YD
TAPE 3"X10YD PAPER HYPO CURAD
MEDLINE
MEDLINE
MEDLINE
MEDLINE
MEDLINE
MEDLINE
A4450
A4450
A4450
A4450
A4450
A4450
1 RL MO/SITE
1 RL MO/SITE
1 RL MO/SITE
1 RL MO/SITE
1 RL MO/SITE
1 RL MO/SITE
NO
NO
NO
NO
NO
NO
1
1
1
12
6
4
BX
BX
BX
BX
BX
BX
TAPE 1/2 HY X 5YD
CURAD, WATERPROOF TAPE, 1X10
CURAD, WATERPROOF TAPE, 2X10
CURAD, WATERPROOF TAPE, 3X10
TAPE 4"X11YD MEDFIX SELF WOUND
I.S.G.
MEDLINE
MEDLINE
MEDLINE
MEDLINE
A4452
A4452
A4452
A4452
A4452
1 RL MO/SITE
1 RL MO/SITE
1 RL MO/SITE
1 RL MO/SITE
1 RL MO/SITE
NO
NO
NO
NO
NO
5
12
6
48
12
BX
BX
BX
CS
BX
A6257
A6257
3/WEEK
3/WEEK
YES
YES
100
50
BX
BX
TRANSPARENT FILM - Little or no drainage; at least 2” larger than perimeter of wound.
16 SQ IN. OR LESS
MSC2302
MSC2705
SURESITE, WINDOW, 2.375X2.75
SURESITE 4X4.8
MEDLINE
MEDLINE
Appendix G PAGE 6
Surgical Dressing/Wound Care
PRODUCT COVERAGE CRITERIA CHART
ITEM #
ITEM DESCRIPTION
MANUFAC.
HCPCS
MAX QTY
ALLOWED
DEBRIDING
AGENT
QTY
UOM
MEDLINE
3M CORP
MEDLINE
MEDLINE
A6257
A6258
A6258
A6258
3/WEEK
3/WEEK
3/WEEK
3/WEEK
YES
YES
YES
YES
50
25
25
50
BX
BX
BX
BX
MEDLINE
A6259
3/WEEK
YES
25
BX
HOLLISTER
HOLLISTER
MEDLINE
MEDLINE
MEDLINE
MEDLINE
MEDLINE
A6260
A6260
A6260
A4245
A4247
A4402
A4332
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
12
12
6
1
100
12
144
CS
CS
CS
EA
BX
BX
BX
MORE THAN 16 SQ IN. BUT LESS THAN OR EQUAL TO 48 SQ IN.
MSC2304
SURESITE 123 TRANSP. FILM 4X4.5
16503M
TERGADERM DRSG 4"X6 18"
MSC2706
SURESITE 6X8 TRANS DRSG
MSC2204
SURESITE 4X4.5 MATRIX TRANS DRSG
MORE THAN 48 SQ IN.
MSC2712
SURESITE 123 TRANSP. FILM 8X12
PPL ITEMS WITH NO HCPCS CATEGORY LISTED
529976
529975
MSC6008
MDS090735
MDS093917
DAY020536
MDS032273
RESTORE WOUND CLEANSER 12 OZ
RESTORE WOUND CLEANSER 8 OZ SPRAY
SKINTEGRITY WOUND CLEANSER 8 OZ
ALCOHOL PREP PAD 200S 2PLY MED
POVIDONE PREP PAD MDM
SURGILUBE JELLY 4.25 OZ TUBE ST
LUBRICANT JELLY 3 GRAM FOIL PK
Appendix G PAGE 7