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Tissue-Engineered Skin Substitutes

Page 1 of 159 Medical Coverage Policy: 0068 Medical Coverage Policy Effective Date .. 11/15/2022 Next Review Date .. 3/15/2023 Coverage Policy Number .. 0068 Tissue-Engineered Skin Substitutes Table of Contents Overview .. 1 Coverage Policy .. 1 General Background .. 24 Medicare Coverage Determinations .. 109 Coding Information .. 110 References .. 117 Related Coverage Resources Autologous Platelet Derived Growth Factors (Platelet-Rich Plasma [PRP]) Bone, Cartilage, Ligament Graft Substitutes Breast Reconstruction Following Mastectomy or Lumpectomy Electrical Stimulation Therapy and Devices in a Home Setting Hyperbaric & Topical Oxygen Therapies Injectable Fillers Lumbar Fusion for Spinal Instability and Degenerative Disc Conditions, Including Sacroiliac Fusion Negative Pressure Wound Therapy/Vacuum-Assisted Closure (VAC) for Nonhealing Wounds Plantar Fasciitis Treatments Scar Revision INSTRUCTIONS

® Venous stasis ulcer Considered medically necessary when BOTH of the following criteria are met: • partial- or full-thickness venous stasis ulcer of greater than four weeks duration for which standard wound therapy has failed • treated lower extremity has adequate blood supply as evidenced by either the

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