Corporate Medical Policy

Medical Supplies and Surgical Dressings

File Name: medical_supplies_and_surgical_dressingsPolicy Number: MED1300Origination: 7/1999Last Review: 8/2008

Active policy, no longer scheduled for routine literature review.

Description of Procedure or Service

Medical supplies consist of items which are primarily and customarily used to serve a medical purpose; are ordered or prescribed by a physician; and are not useful to a person in the absence of illness or injury. Medi-cal supplies cannot withstand repeated use and are usually disposable in nature. Surgical dressings are thera-peutic or protective coverings applied directly to wounds or lesions either on the skin or caused by an opening to the skin.

Policy

Active policy, no longer scheduled for routine literature review.

BCBSNC will provide coverage for Medical Supplies and Surgical Dressings when they are deter-mined to be medically necessary because they meet the medical criteria and guidelines shown below. Medical supplies and surgical dressings must have proven medical value and be appropriate for the treatment of the patient’s condition.

Benefits Application

Please refer to Certificate for availability of benefit. See Medical Supplies under Other Services. This policy relates only to the services or supplies described herein. Benefits may vary according to benefit design, therefore certificate language should be reviewed before applying the terms of the policy.

Please refer to individual policies (for example, Diabetes, Oxygen and Oxygen supplies, and Home Infusion Therapy for additional information regarding specific medical supplies associated with those services).

When Medical Supplies and Surgical Dressings are covered

A. Medical supplies and surgical dressings will be covered when all of the following criteria are met:

1. they are medically necessary; and

2. they are prescribed by a physician; and

3. they are appropriate for the treatment of the patient’s condition; and

4. they are used primarily for the physician’s supervised treatment of a medical illness or injury.

Policy: Medical Supplies and Surgical Dressings

Coverage for medical supplies includes, but is not limited to the following items:

♦ Ostomy supplies

♦ Catheters

♦ Diabetic supplies

♦ Sterile syringes and needles

♦ Surgical dressings

B. Surgical dressings are covered when all the following criteria are met:

1. They are medically necessary for the treatment of a wound caused by, or treated by, a surgical proce-dure; or are medically necessary when debridement of a wound is medically necessary; and

2. they are prescribed by a physician; and

3. they are appropriate for the treatment of the patient’s wound; and

4. they are used primarily for the physician’s supervised treatment of the wound.

Surgical dressings include both primary dressings (for example, therapeutic or protective coverings applied directly to wounds or lesions either on the skin or caused by an opening to the skin) and secondary dressings (for example, materials that serve a therapeutic or protective function and are needed to secure a primary dressing). For example, elastic bandages, adhesive tape, elastic roll gauze, and non-elastic roll gauze are covered when used as a secondary dressing to hold wound cover dressings in place.

When Medical Supplies and Surgical Dressings are not covered

1. When the criteria under A. and B. (listed above) are not met,

2. When they are items usually stocked in the home for general use,

3. When they are considered a routine part of the doctor’s office visit. If a specialist applies a surgical dressing as part of a professional service, the surgical dressings are considered incidental to the profes-sional service and are not reimbursed separate from the office visit.

Examples of non-covered items include, but are not limited to the following:

• band-aids

• lubricating jelly

• thermometers

• incontinence supplies

• disposable underpads

• support hose

• garter belts

• foot coverings

• leotards

• knee supports

• surgical leggings

• gauntlets

• pressure garments for the arms and hands

Policy: Medical Supplies and Surgical Dressings

• elastic bandages when they are used over a wound cover with adhesive border or over a wound cover held in place by tape, elastic roll gauze, or non-elastic roll gauze, or transparent film

• elastic bandages when they are used for strains, sprains, edema, or situations other than as a secondary surgical dressing.

Examples of situations in which dressings are non-covered under the surgical dressing benefit either in or out of the office are:

• drainage from a cutaneous fistula which has not been caused by or treated by a surgical proce-dure; or

• a Stage I pressure ulcer; or

• a first degree burn; or

• wounds caused by trauma which do not require surgical closure or debridement (for example, skin tears or abrasions); or

• a venipuncture or arterial puncture site (for example, a blood sample) other than the site of an indwelling catheter or needle.

Policy Guidelines

Not applicable.

Billing/Coding/Physician Documentation Information

This policy may apply to the following codes. Inclusion of a code in this section does not guarantee that it will be reimbursed. For further information on reimbursement guidelines, please see Administrative Policies on the Blue Cross Blue Shield of North Carolina web site at www.bcbsnc.com. They are listed in the Cate-gory Search on the Medical Policy search page.

Applicable codes: A4206-A7527, 99070.

Policy Key Words

Key Words: Medical supplies, Surgical dressings, Gauze, Tape, Elastic bandage, Support stockings, MED1300

Medical Term Definitions

Cutaneous fistulaan abnormal passage or communication leading from an internal organ to the surface of the body.

BCBSNC may request medical records for determination of medical necessity. When medical records arerequested, letters of support and/or explanation are often useful, but are not sufficient documentation unlessall specific information needed to make a medical necessity determination is included.

Policy: Medical Supplies and Surgical Dressings

Debrideto remove dead, infected, contaminated, or foreign material.

Ostomya surgical procedure to create an opening from an area inside the body to the outside.

Scientific Background and Reference Sources

BCBSA Medical Policy Reference Manual 12/95

Medicare Region C DMERC; Autumn 1998 Manual Revision; pps. 61.4-61.5, 61.8

Specialty Matched Consultant Advisory Group - 10/2000

Medical Policy Advisory Group - 10/2000

Specialty Matched Consultant Advisory Group - 8/2002

Specialty Matched Consultant Advisory Panel - 8/2004

Specialty Matched Consultant Advisory Panel - 8/2006

Policy Implementation/Update Information

7/99 Original policy issued.

8/99 Reformatted; Medical Term Definitions added.

10/00 Specialty Matched Consultant Advisory Group review. No recommendations for changes to crite-ria. Medical Policy Advisory Group review. No change in criteria. Approve.

10/02 Specialty Matched Consultant Advisory Group review 8/15/02. No changes to criteria recom-mended. Under when not covered section, bullet three, next to the last statement, added "cover" to clarify statement "or over a wound cover held in place...." System coding changes.

5/13/04 Benefits Application and Billing/Coding sections updated for consistency.

10/28/04Removed elastic support/stockings from list of noncovered items. Support hose remain in the non-covered list, and that is what was referred to by the elastic support/stockings. Specialty Matched Consultant Advisory Panel review.

12/11/06Specialty Matched Consultant Advisory Panel review. No changes to criteria. Code range in Bill-ing/Coding section now includes A4206 through A7527.

9/22/08 Policy status changed to "Active policy, no longer scheduled for routine literature review."

Medical policy is not an authorization, certification, explanation of benefits or a contract. Benefits and eligibility are deter-mined before medical guidelines and payment guidelines are applied. Benefits are determined by the group contract and sub-scriber certificate that is in effect at the time services are rendered. This document is solely provided for informational purposes only and is based on research of current medical literature and review of common medical practices in the treatment and diagnosis of disease. Medical practices and knowledge are constantly changing and BCBSNC reserves the right to review and revise its medical policies periodically.