663 Bioengineered Skin And Soft Tissue Substitutes

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Medical PolicyBioengineered Skin and Soft Tissue SubstitutesTable of Contents Policy: Commercial Coding Information Information Pertaining to All Policies Policy: Medicare Description References Authorization Information Policy History EndnotesPolicy Number: 663BCBSA Reference Number: 7.01.113NCD/LCD: N/ARelated PoliciesAmniotic Membrane and Amniotic Fluid, #643PolicyCommercial Members: Managed Care (HMO and POS), PPO, and IndemnityMedicare HMO BlueSM and Medicare PPO BlueSM MembersBreast reconstructive surgery following cancer treatment using allogeneic acellular dermal matrixproductsa may be considered MEDICALLY NECESSARY.1Penile construction following transgender surgery using Alloderm is covered. 1Treatment of chronic, noninfected, full-thickness diabetic lower extremity ulcers using the following tissueengineered skin substitutes may be considered MEDICALLY NECESSARY: AlloPatch aApligraf bDermagraft bIntegra Omnigraft Dermal Regeneration Matrix (also known as Omnigraft ) and Integra FlowableWound Matrix.Treatment of chronic, non-infected, partial- or full-thickness lower extremity skin ulcers due to venousinsufficiency, which have not adequately responded following a 1-month period of conventional ulcertherapy, using the following tissue-engineered skin substitutes may be considered MEDICALLYNECESSARY: Apligraf bOasis Wound Matrixc.1

Treatment of dystrophic epidermolysis bullosa using the following tissue-engineered skin substitutes maybe considered MEDICALLY NECESSARY: OrCel (for the treatment of mitten-hand deformity when standard wound therapy has failed andwhen provided in accordance with the humanitarian device exemption [HDE] specifications of theU.S. Food and Drug Administration [FDA]) d.Treatment of second- and third-degree burns using the following tissue-engineered skin substitutes maybe considered MEDICALLY NECESSARY: Epicel (for the treatment of deep dermal or full-thickness burns comprising a total body surface area 30% when provided in accordance with the HDE specifications of the FDA) dIntegra Dermal Regeneration Templateb.aBanked human tissue.FDA premarket approval.c FDA 510(k) clearance.d FDA-approved under an HDE.bAll other uses of the bio-engineered skin and soft tissue substitutes listed above are consideredINVESTIGATIONAL.All other skin and soft tissue substitutes not listed above are considered INVESTIGATIONAL, including,but not limited to: ACell UBM Hydated/ Lyophilized Wound DressingAlloSkin AlloSkin RTAongen Collagen MatrixArchitect ECM, PX, FXArthroFlex (Flex Graft)Atlas Wound MatrixAvagen Wound DressingAxoGuard Nerve Protector (AxoGen)Biobrane /Biobrane-LCollaCare CollaCare DentalCollagen Wound Dressing (Oasis Research)CollaGUARD CollaMend CollaWound Collexa Collieva Conexa Coreleader Colla-PadCorMatrix Cymetra (Micronized AlloDerm Cytal (previously MatriStem )Dermadapt Wound DressingDermaPure DermaSpan DressSkinDurepair Regeneration Matrix Endoform Dermal Template ENDURAgen 2

ExcellagenExpressGraft E-Z Derm FlexiGraft GammaGraftGraftJacket Xpress, injectableHelicoll Hyalomatrix Hyalomatrix PAhMatrix Integra Bilayer Wound MatrixKeramatrix Kerecis MariGen /Kerecis Omega3 MatriDerm Matrix HD Mediskin MemoDerm Microderm biologic wound matrixNeoForm NuCelOasis Burn MatrixOasis UltraPelvicol /PelviSoft Permacol PriMatrixPrimatrix Dermal Repair ScaffoldPuraPly Wound Matrix (previously FortaDerm )PuraPly AM (Antimicrobial Wound Matrix)Puros DermisRegenePro Repliform Repriza StrataGraft Strattice (xenograft)Suprathel SurgiMend Talymed TenoGlide TenSIX Acellular Dermal MatrixTissueMendTheraForm Standard/SheetTheraSkin TransCyte TruSkin Veritas Collagen MatrixXCM Biologic Tissue MatrixXenMatrix AB.Prior Authorization InformationInpatient For services described in this policy, precertification/preauthorization IS REQUIRED for all products ifthe procedure is performed inpatient.Outpatient3

For services described in this policy, see below for products where prior authorization might berequired if the procedure is performed outpatient.Commercial Managed Care (HMO and POS)Commercial PPO and IndemnityMedicare HMO BlueSMMedicare PPO BlueSMOutpatientPrior authorization is not required.Prior authorization is not required.Prior authorization is not required.Prior authorization is not required.CPT Codes / HCPCS Codes / ICD CodesInclusion or exclusion of a code does not constitute or imply member coverage or providerreimbursement. Please refer to the member’s contract benefits in effect at the time of service to determinecoverage or non-coverage as it applies to an individual member.Providers should report all services using the most up-to-date industry-standard procedure, revenue, anddiagnosis codes, including modifiers where applicable.The following codes are included below for informational purposes only; this is not an all-inclusive list.The above medical necessity criteria MUST be met for the following codes to be covered forCommercial Members: Managed Care (HMO and POS), PPO, Indemnity, Medicare HMO Blue andMedicare PPO Blue:CPT CodesCPT codes:1527115272152731527415275152761527715278Code DescriptionApplication of skin substitute graft to trunk, arms, legs, total wound surface area up to100 sq cm; first 25 sq cm or less wound surface areaApplication of skin substitute graft to trunk, arms, legs, total wound surface area up to100 sq cm; each additional 25 sq cm wound surface area, or part thereof (Listseparately inaddition to code for primary procedure)Application of skin substitute graft to trunk, arms, legs, total wound surface area greaterthan or equal to 100 sq cm; first 100 sq cm wound surface area, or 1% of body area ofinfants and childrenApplication of skin substitute graft to trunk, arms, legs, total wound surface area greaterthan or equal to 100 sq cm; each additional 100 sq cm wound surface area, or partthereof, or each additional 1% of body area of infants and children, or part thereof (Listseparately in addition to code for primary procedure)Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits,genitalia, hands, feet, and/or multiple digits, total wound surface area up to 100 sq cm;first 25 sq cm or less wound surface areaApplication of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits,genitalia, hands, feet, and/or multiple digits, total wound surface area up to 100 sq cm;each additional 25 sq cm wound surface area, or part thereof (List separately inaddition to code for primary procedure)Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits,genitalia, hands, feet, and/or multiple digits, total wound surface area greater than orequal to 100 sq cm; first 100 sq cm wound surface area, or 1% of body area of infantsand childrenApplication of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits,genitalia, hands, feet, and/or multiple digits, total wound surface area greater than orequal to 100 sq cm; each additional 100 sq cm wound surface area, or part thereof, or4

15777each additional 1% of body area of infants and children, or part thereof (List separatelyin addition to code for primary procedure)Implantation of biologic implant (eg, acellular dermal matrix) for soft tissuereinforcement (eg, breast, trunk) (List separately in addition to code for primaryprocedure)The above medical necessity criteria MUST be met for the following codes to be covered forCommercial Members: Managed Care (HMO and POS), PPO, Indemnity, Medicare HMO Blue andMedicare PPO Blue:Breast Reconstructive SurgeryHCPCS CodesHCPCScodes:Q4100Q4107Q4116Q4122Q4128Code DescriptionSkin substitute, not otherwise specified**for use with AlloMax , AlloMend ,DermaMatrix ,GRAFTJACKET, per sq cmAlloDerm, per sq cmDermacell, dermacell awm or dermacell awm porous, per square centimeterFlexHD, AllopatchHD, or Matrix HD, per sq cmThe following ICD Diagnosis Codes are considered medically necessary when submitted with theHCPCS codes above if medical necessity criteria are met:ICD-10 Diagnosis de DescriptionMalignant neoplasm of nipple and areola, right female breastMalignant neoplasm of nipple and areola, left female breastMalignant neoplasm of nipple and areola, unspecified female breastMalignant neoplasm of nipple and areola, right male breastMalignant neoplasm of nipple and areola, left male breastMalignant neoplasm of nipple and areola, unspecified male breastMalignant neoplasm of central portion of right female breastMalignant neoplasm of central portion of left female breastMalignant neoplasm of central portion of unspecified female breastMalignant neoplasm of central portion of right male breastMalignant neoplasm of central portion of left male breastMalignant neoplasm of central portion of unspecified male breastMalignant neoplasm of upper-inner quadrant of right female breastMalignant neoplasm of upper-inner quadrant of left female breastMalignant neoplasm of upper-inner quadrant of unspecified female breastMalignant neoplasm of upper-inner quadrant of right male breastMalignant neoplasm of upper-inner quadrant of left male breastMalignant neoplasm of upper-inner quadrant of unspecified male breastMalignant neoplasm of lower-inner quadrant of right female breastMalignant neoplasm of lower-inner quadrant of left female breastMalignant neoplasm of lower-inner quadrant of unspecified female breastMalignant neoplasm of lower-inner quadrant of right male breastMalignant neoplasm of lower-inner quadrant of left male breastMalignant neoplasm of lower-inner quadrant of unspecified male breast5

922C50.929F64.0F64.1F64.2F64.8F64.9Malignant neoplasm of upper-outer quadrant of right female breastMalignant neoplasm of upper-outer quadrant of left female breastMalignant neoplasm of upper-outer quadrant of unspecified female breastMalignant neoplasm of upper-outer quadrant of right male breastMalignant neoplasm of upper-outer quadrant of left male breastMalignant neoplasm of upper-outer quadrant of unspecified male breastMalignant neoplasm of lower-outer quadrant of right female breastMalignant neoplasm of lower-outer quadrant of left female breastMalignant neoplasm of lower-outer quadrant of unspecified female breastMalignant neoplasm of lower-outer quadrant of right male breastMalignant neoplasm of lower-outer quadrant of left male breastMalignant neoplasm of lower-outer quadrant of unspecified male breastMalignant neoplasm of axillary tail of right female breastMalignant neoplasm of axillary tail of left female breastMalignant neoplasm of axillary tail of unspecified female breastMalignant neoplasm of axillary tail of right male breastMalignant neoplasm of axillary tail of left male breastMalignant neoplasm of axillary tail of unspecified male breastMalignant neoplasm of overlapping sites of right female breastMalignant neoplasm of overlapping sites of left female breastMalignant neoplasm of overlapping sites of unspecified female breastMalignant neoplasm of overlapping sites of right male breastMalignant neoplasm of overlapping sites of left male breastMalignant neoplasm of overlapping sites of unspecified male breastMalignant neoplasm of unspecified site of right female breastMalignant neoplasm of unspecified site of left female breastMalignant neoplasm of unspecified site of unspecified female breastMalignant neoplasm of unspecified site of right male breastMalignant neoplasm of unspecified site of left male breastMalignant neoplasm of unspecified site of unspecified male breastTranssexualismGender identity disorder in adolescence and adulthoodGender identity disorder of childhoodOther identity disordersGender identity disorder, unspecifiedThe above medical necessity criteria MUST be met for the following codes to be covered forCommercial Members: Managed Care (HMO and POS), PPO, Indemnity, Medicare HMO Blue andMedicare PPO Blue:Diabetic Lower Extremity UlcersHCPCS CodesHCPCScodes:Q4101Q4105Q4106Q4114Q4128Code DescriptionApligraf, per sq cmIntegra dermal regeneration template (DRT) or Integra Omnigraft dermal regenerationmatrix, per square centimeterDermagraft, per sq cmIntegra flowable wound matrix, injectable, 1 ccFlexHD, AllopatchHD, or Matrix HD, per sq cm6

The following ICD Diagnosis Codes are considered medically necessary when submitted with theHCPCS codes above if medical necessity criteria are met:ICD-10 Diagnosis Code DescriptionDiabetes mellitus due to underlying condition with foot ulcerDiabetes mellitus due to underlying condition with other skin ulcerDrug or chemical induced diabetes mellitus with foot ulcerDrug or chemical induced diabetes mellitus with other skin ulcerType 1 diabetes mellitus with foot ulcerType 1 diabetes mellitus with other skin ulcerType 2 diabetes mellitus with foot ulcerType 2 diabetes mellitus with other skin ulcerOther specified diabetes mellitus with foot ulcerOther specified diabetes mellitus with other skin ulcerThe above medical necessity criteria MUST be met for the following codes to be covered forCommercial Members: Managed Care (HMO and POS), PPO, Indemnity, Medicare HMO Blue andMedicare PPO Blue:Lower Extremity Skin Ulcers Due to Venous InsufficiencyHCPCS CodesHCPCScodes:Q4101Q4102Code DescriptionApligraf, per sq cmOasis wound matrix, per sq cmThe following ICD Diagnosis Codes are considered medically necessary when submitted with theHCPCS codes above if medical necessity criteria are met:ICD-10 Diagnosis 7.116Code DescriptionVenous insufficiency (chronic) (peripheral)Non-pressure chronic ulcer of unspecified thigh limited to breakdown of skinNon-pressure chronic ulcer of unspecified thigh with fat layer exposedNon-pressure chronic ulcer of unspecified thigh with muscle involvement withoutevidence of necrosisNon-pressure chronic ulcer of unspecified thigh with bone involvement without evidenceof necrosisNon-pressure chronic ulcer of unspecified thigh with other specified severityNon-pressure chronic ulcer of unspecified thigh with unspecified severityNon-pressure chronic ulcer of right thigh limited to breakdown of skinNon-pressure chronic ulcer of right thigh with fat layer exposedNon-pressure chronic ulcer of right thigh with muscle involvement without evidence ofnecrosisNon-pressure chronic ulcer of right thigh with bone involvement without evidence ofnecrosis7

16L97.318L97.319L97.321L97.322Non-pressure chronic ulcer of right thigh with other specified severityNon-pressure chronic ulcer of right thigh with unspecified severityNon-pressure chronic ulcer of left thigh limited to breakdown of skinNon-pressure chronic ulcer of left thigh with fat layer exposedNon-pressure chronic ulcer of left thigh with muscle involvement without evidence ofnecrosisNon-pressure chronic ulcer of left thigh with bone involvement without evidence ofnecrosisNon-pressure chronic ulcer of left thigh with other specified severityNon-pressure chronic ulcer of left thigh with unspecified severityNon-pressure chronic ulcer of unspecified calf limited to breakdown of skinNon-pressure chronic ulcer of unspecified calf with fat layer exposedNon-pressure chronic ulcer of unspecified calf with muscle involvement withoutevidence of necrosisNon-pressure chronic ulcer of unspecified calf with bone involvement without evidenceof necrosisNon-pressure chronic ulcer of unspecified calf with other specified severityNon-pressure chronic ulcer of unspecified calf with unspecified severityNon-pressure chronic ulcer of right calf limited to breakdown of skinNon-pressure chronic ulcer of right calf with fat layer exposedNon-pressure chronic ulcer of right calf with muscle involvement without evidence ofnecrosisNon-pressure chronic ulcer of right calf with bone involvement without evidence ofnecrosisNon-pressure chronic ulcer of right calf with other specified severityNon-pressure chronic ulcer of right calf with unspecified severityNon-pressure chronic ulcer of left calf limited to breakdown of skinNon-pressure chronic ulcer of left calf with fat layer exposedNon-pressure chronic ulcer of left calf with muscle involvement without evidence ofnecrosisNon-pressure chronic ulcer of left calf with bone involvement without evidence ofnecrosisNon-pressure chronic ulcer of left calf with other specified severityNon-pressure chronic ulcer of left calf with unspecified severityNon-pressure chronic ulcer of unspecified ankle limited to breakdown of skinNon-pressure chronic ulcer of unspecified ankle with fat layer exposedNon-pressure chronic ulcer of unspecified ankle with muscle involvement withoutevidence of necrosisNon-pressure chronic ulcer of unspecified ankle with bone involvement withoutevidence of necrosisNon-pressure chronic ulcer of unspecified ankle with other specified severityNon-pressure chronic ulcer of unspecified ankle with unspecified severityNon-pressure chronic ulcer of right ankle limited to breakdown of skinNon-pressure chronic ulcer of right ankle with fat layer exposedNon-pressure chronic ulcer of right ankle with muscle involvement without evidence ofnecrosisNon-pressure chronic ulcer of right ankle with bone involvement without evidence ofnecrosisNon-pressure chronic ulcer of right ankle with other specified severityNon-pressure chronic ulcer of right ankle with unspecified severityNon-pressure chronic ulcer of left ankle limited to breakdown of skinNon-pressure chronic ulcer of left ankle with fat layer exposed8

22L97.525L97.526L97.528Non-pressure chronic ulcer of left ankle with muscle involvement without evidence ofnecrosisNon-pressure chronic ulcer of left ankle with bone involvement without evidence ofnecrosisNon-pressure chronic ulcer of left ankle with other specified severityNon-pressure chronic ulcer of left ankle with unspecified severityNon-pressure chronic ulcer of unspecified heel and midfoot limited to breakdown of skinNon-pressure chronic ulcer of unspecified heel and midfoot with fat layer exposedNon-pressure chronic ulcer of unspecified heel and midfoot with muscle involvementwithout evidence of necrosisNon-pressure chronic ulcer of unspecified heel and midfoot with bone involvementwithout evidence of necrosisNon-pressure chronic ulcer of unspecified heel and midfoot with other specified severityNon-pressure chronic ulcer of unspecified heel and midfoot with unspecified severityNon-pressure chronic ulcer of right heel and midfoot limited to breakdown of skinNon-pressure chronic ulcer of right heel and midfoot with fat layer exposedNon-pressure chronic ulcer of right heel and midfoot with muscle involvement withoutevidence of necrosisNon-pressure chronic ulcer of right heel and midfoot with bone involvement withoutevidence of necrosisNon-pressure chronic ulcer of right heel and midfoot with other specified severityNon-pressure chronic ulcer of right heel and midfoot with unspecified severityNon-pressure chronic ulcer of left heel and midfoot limited to breakdown of skinNon-pressure chronic ulcer of left heel and midfoot with fat layer exposedNon-pressure chronic ulcer of left heel and midfoot with muscle involvement withoutevidence of necrosisNon-pressure chronic ulcer of left heel and midfoot with bone involvement withoutevidence of necrosisNon-pressure chronic ulcer of left heel and midfoot with other specified severityNon-pressure chronic ulcer of left heel and midfoot with unspecified severityNon-pressure chronic ulcer of other part of unspecified foot limited to breakdown of skinNon-pressure chronic ulcer of other part of unspecified foot with fat layer exposedNon-pressure chronic ulcer of other part of unspecified foot with muscle involvementwithout evidence of necrosisNon-pressure chronic ulcer of other part of unspecified foot with bone involvementwithout evidence of necrosisNon-pressure chronic ulcer of other part of unspecified foot with other specified severityNon-pressure chronic ulcer of other part of unspecified foot with unspecified severityNon-pressure chronic ulcer of other part of right foot limited to breakdown of skinNon-pressure chronic ulcer of other part of right foot with fat layer exposedNon-pressure chronic ulcer of other part of right foot with muscle involvement withoutevidence of necrosisNon-pressure chronic ulcer of other part of right foot with bone involvement withoutevidence of necrosisNon-pressure chronic ulcer of other part of right foot with other specified severityNon-pressure chronic ulcer of other part of right foot with unspecified severityNon-pressure chronic ulcer of other part of left foot limited to breakdown of skinNon-pressure chronic ulcer of other part of left foot with fat layer exposedNon-pressure chronic ulcer of other part of left foot with muscle involvement withoutevidence of necrosisNon-pressure chronic ulcer of other part of left foot with bone involvement withoutevidence of necrosisNon-pressure chronic ulcer of other part of left foot with other specified severity9

916L97.918L97.919L97.921L97.922Non-pressure chronic ulcer of other part of left foot with unspecified severityNon-pressure chronic ulcer of other part of unspecified lower leg limited to breakdownof skinNon-pressure chronic ulcer of other part of unspecified lower leg with fat layer exposedNon-pressure chronic ulcer of other part of unspecified lower leg with muscleinvolvement without evidence of necrosisNon-pressure chronic ulcer of other part of unspecified lower leg with bone involvementwithout evidence of necrosisNon-pressure chronic ulcer of other part of unspecified lower leg with other specifiedseverityNon-pressure chronic ulcer of other part of unspecified lower leg with unspecifiedseverityNon-pressure chronic ulcer of other part of right lower leg limited to breakdown of skinNon-pressure chronic ulcer of other part of right lower leg with fat layer exposedNon-pressure chronic ulcer of other part of right lower leg with muscle involvementwithout evidence of necrosisNon-pressure chronic ulcer of other part of right lower leg with bone involvement withoutevidence of necrosisNon-pressure chronic ulcer of other part of right lower leg with other specified severityNon-pressure chronic ulcer of other part of right lower leg with unspecified severityNon-pressure chronic ulcer of other part of left lower leg limited to breakdown of skinNon-pressure chronic ulcer of other part of left lower leg with fat layer exposedNon-pressure chronic ulcer of other part of left lower leg with muscle involvementwithout evidence of necrosisNon-pressure chronic ulcer of other part of left lower leg with bone involvement withoutevidence of necrosisNon-pressure chronic ulcer of other part of left lower leg with other specified severityNon-pressure chronic ulcer of other part of left lower leg with unspecified severityNon-pressure chronic ulcer of unspecified part of unspecified lower leg limited tobreakdown of skinNon-pressure chronic ulcer of unspecified part of unspecified lower leg with fat layerexposedNon-pressure chronic ulcer of unspecified part of unspecified lower leg with muscleinvolvement without evidence of necrosisNon-pressure chronic ulcer of unspecified part of unspecified lower leg with boneinvolvement without evidence of necrosisNon-pressure chronic ulcer of unspecified part of unspecified lower leg with otherspecified severityNon-pressure chronic ulcer of unspecified part of unspecified lower leg with unspecifiedseverityNon-pressure chronic ulcer of unspecified part of right lower leg limited to breakdown ofskinNon-pressure chronic ulcer of unspecified part of right lower leg with fat layer exposedNon-pressure chronic ulcer of unspecified part of right lower leg with muscleinvolvement without evidence of necrosisNon-pressure chronic ulcer of unspecified part of right lower leg with bone involvementwithout evidence of necrosisNon-pressure chronic ulcer of unspecified part of right lower leg with other specifiedseverityNon-pressure chronic ulcer of unspecified part of right lower leg with unspecifiedseverityNon-pressure chronic ulcer of unspecified part of left lower leg limited to breakdown ofskinNon-pressure chronic ulcer of unspecified part of left lower leg with fat layer exposed10

L97.925L97.926L97.928L97.929Non-pressure chronic ulcer of unspecified part of left lower leg with muscle involvementwithout evidence of necrosisNon-pressure chronic ulcer of unspecified part of left lower leg with bone involvementwithout evidence of necrosisNon-pressure chronic ulcer of unspecified part of left lower leg with other specifiedseverityNon-pressure chronic ulcer of unspecified part of left lower leg with unspecified severityThe above medical necessity criteria MUST be met for the following codes to be covered forCommercial Members: Managed Care (HMO and POS), PPO, Indemnity, Medicare HMO Blue andMedicare PPO Blue:Dystrophic Epidermolysis BullosaHCPCS CodesHCPCScodes:Q4100Code DescriptionSkin substitute, not otherwise specified**for use with OrCel The above medical necessity criteria MUST be met for the following codes to be covered forCommercial Members: Managed Care (HMO and POS), PPO, Indemnity, Medicare HMO Blue andMedicare PPO Blue:Second- and Third-Degree BurnsHCPCS CodesHCPCScodes:Q4100Q4105Code DescriptionSkin substitute, not otherwise specified**for use with Epicel Integra dermal regeneration template (drt) or integra omnigraft dermal regenerationmatrix, per square centimeterThe following ICD Diagnosis Codes are considered medically necessary when submitted with theHCPCS codes above if medical necessity criteria are met:ICD-10 Diagnosis 2ST20.219AT20.219DT20.219ST20.22XACode DescriptionBurn of second degree of head, face, and neck, unspecified site, initial encounterBurn of second degree of head, face, and neck, unspecified site, subsequent encounterBurn of second degree of head, face, and neck, unspecified site, sequelaBurn of second degree of right ear [any part, except ear drum], initial encounterBurn of second degree of right ear [any part, except ear drum], subsequent encounterBurn of second degree of right ear [any part, except ear drum], sequelaBurn of second degree of left ear [any part, except ear drum], initial encounterBurn of second degree of left ear [any part, except ear drum], subsequent encounterBurn of second degree of left ear [any part, except ear drum], sequelaBurn of second degree of unspecified ear [any part, except ear drum], initial encounterBurn of second degree of unspecified ear [any part, except ear drum], subsequentencounterBurn of second degree of unspecified ear [any part, except ear drum], sequelaBurn of second degree of lip(s), initial encounter11

Burn of second degree of lip(s), subsequent encounterBurn of second degree of lip(s), sequelaBurn of second degree of chin, initial encounterBurn of second degree of chin, subsequent encounterBurn of second degree of chin, sequelaBurn of second degree of nose (septum), initial encounterBurn of second degree of nose (septum), subsequent encounterBurn of second degree of nose (septum), sequelaBurn of second degree of scalp [any part], initial encounterBurn of second degree of scalp [any part], subsequent encounterBurn of second degree of scalp [any part], sequelaBurn of second degree of forehead and cheek, initial encounterBurn of second degree of forehead and cheek, subsequent encounterBurn of second degree of forehead and cheek, sequelaBurn of second degree of neck, initial encounterBurn of second degree of neck, subsequent encounterBurn of second degree of neck, sequelaBurn of second degree of multiple sites of head, face, and neck, initial encounterBurn of second degree of multiple sites of head, face, and neck, subsequent encounterBurn of second degree of multiple sites of head, face, and neck, sequelaBurn of third degree of head, face, and neck, unspecified site, initial encounterBurn of third degree of head, face, and neck, unspecified site, subsequent encounterBurn of third degree of head, face, and neck, unspecified site, sequelaBurn of third degree of right ear [any part, except ear drum], initial encounterBurn of third degree of right ear [any part, except ear drum],

4 For services described in this policy, see below for products where prior authorization might be required if the procedure is performed outpatient. Outpatient Commercial Managed Care (HMO and POS) Prior authorization is not required. Commercial PPO and Indemnity Prior authorization is not required. Medicare HMO BlueSM Prior authorization is not required.

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