PA Lookup
If you have questions about prior authorizations, please call:
Member and Recipient Service Line: 1-877-685-2415
Provider Support Service Line: 1-855-250-1539
Q3014 CS Telehealth Originating Site Facility Fee; COVID Cost Sharing
Authorization Guidelines
Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
How to Submit
N/A - No authorization is required
Skin Substitutes
Skin substitutes are used to treat chronic wounds, burns, rare skin conditions, trauma, ischemia, or other neurological impairments; over 90 percent of the lesions are related to venous stasis disease and diabetic neuropathy. These products promote the growth of new skin or serve as a temporary cover until other grafts can be placed. The addition of Skin Substitutes, Cellular or Tissue Based Products (CTPs) to certain wounds may afford a healing advantage over dressings and conservative treatments when these options appear insufficient to affect complete healing. There are currently a wide variety of bioengineered products available for soft tissue coverage to affect closure. These products may be derived from human tissue (allogeneic or autologous), non-human tissue (xenogeneic), synthetic sources or a combination of any or all these types of materials. However, without the component of the recipient’s own distinct epithelium and cellular skin elements, permanent skin replacement or coverage by graft cannot be accomplished.
Authorization Guidelines
Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
Unit Value
One unit equals 1 square centimeter
Limits
.a. Apligraf® is limited to 176 units within 180 calendar days, with no more than four applications per ulcer.
- b. GrafixPrime® is limited to one application per calendar week, for a maximum
of 12 weeks per ulcer.
- c. GrafixCore® is limited to one application per calendar week, for a maximum
of 12 weeks per ulcer.
- d. Amnioband® is limited to one application per seven calendar days, for a
maximum of 12 weeks per ulcer.
- e. Dermagraft®is limited to 304 units within 12 weeks, with no more than 8
applications per ulcer.
- f. Allopatch is limited to one application per seven calendar days for a
maximum of 12 weeks per ulcer.
- g. TheraSkin® is limited to eight applications per ulcer. Each application is
limited to 80 units per day, to a maximum of 640 units every 12 weeks. Reapplication of TheraSkin® within one week for the same ulcer is not allowed.
Re-application of TheraSkin® is not allowed for the same ulcer if satisfactory and reasonable healing progress is not noted after 12 weeks of therapy.
- h. Integra® coverage is limited to the application of a quantity of material that
closely approximates the size of the wound. The number of units billed must closely correlate with the wound size. The maximum daily allowable units are 60.
- i. EpiFix® is limited to ten applications per ulcer; the initial application, then
additional applications may be applied at a minimum of one-week intervals, for up to a maximum of four applications in 12 weeks, when there is evidence of wound healing.
- j. Kerecis® is limited to one application per calendar week, for a maximum of
12 weeks per ulcer.
For burn treatments, reimbursement for physician services is limited to the application of the product.
Exclusions
Must be billed in conjunction with codes that describe application of the tissue and preparation of the site. Medicaid also does not cover skin substitutes for infected ulcers; wounds or ulcers progressing toward closure with traditional wound care; eschar or necrotic material; ulcers with sinus tracts or tunnels; underlying osteomyelitis; surrounding cellulitis; known hypersensitivity to substitute materials; arterial disease with ABI less than 0.70 or lack of pedal pulses; uncontrolled diabetes; active Charcot's arthropathy of the ulcer extremity; vasculitis; uncontrolled rheumatoid arthritis or rheumatoid ulcers; other uncontrolled collagen vascular diseases; treatment with high-dose corticosteroids or immunosuppressants; or radiation or chemotherapy within the month immediately preceding proposed treatment.
Place of Service
Place of service for Dermagraft® Apligraf®, EpiFix®, TheraSkin®, GrafixCore®, GrafixPrime®, Allopatch®, Amnioband® and Kerecis® is limited to inpatient, outpatient hospital, and office.
Place of service for Integra® and AlloDerm® is limited to inpatient and outpatient hospital.
How to Submit
N/A - No authorization is required
Resources
Skin Substitutes
Skin substitutes are used to treat chronic wounds, burns, rare skin conditions, trauma, ischemia, or other neurological impairments; over 90 percent of the lesions are related to venous stasis disease and diabetic neuropathy. These products promote the growth of new skin or serve as a temporary cover until other grafts can be placed. The addition of Skin Substitutes, Cellular or Tissue Based Products (CTPs) to certain wounds may afford a healing advantage over dressings and conservative treatments when these options appear insufficient to affect complete healing. There are currently a wide variety of bioengineered products available for soft tissue coverage to affect closure. These products may be derived from human tissue (allogeneic or autologous), non-human tissue (xenogeneic), synthetic sources or a combination of any or all these types of materials. However, without the component of the recipient’s own distinct epithelium and cellular skin elements, permanent skin replacement or coverage by graft cannot be accomplished.
Authorization Guidelines
Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
Unit Value
One unit equals 1 square centimeter
Limits
.a. Apligraf® is limited to 176 units within 180 calendar days, with no more than four applications per ulcer.
- b. GrafixPrime® is limited to one application per calendar week, for a maximum
of 12 weeks per ulcer.
- c. GrafixCore® is limited to one application per calendar week, for a maximum
of 12 weeks per ulcer.
- d. Amnioband® is limited to one application per seven calendar days, for a
maximum of 12 weeks per ulcer.
- e. Dermagraft®is limited to 304 units within 12 weeks, with no more than 8
applications per ulcer.
- f. Allopatch is limited to one application per seven calendar days for a
maximum of 12 weeks per ulcer.
- g. TheraSkin® is limited to eight applications per ulcer. Each application is
limited to 80 units per day, to a maximum of 640 units every 12 weeks. Reapplication of TheraSkin® within one week for the same ulcer is not allowed.
Re-application of TheraSkin® is not allowed for the same ulcer if satisfactory and reasonable healing progress is not noted after 12 weeks of therapy.
- h. Integra® coverage is limited to the application of a quantity of material that
closely approximates the size of the wound. The number of units billed must closely correlate with the wound size. The maximum daily allowable units are 60.
- i. EpiFix® is limited to ten applications per ulcer; the initial application, then
additional applications may be applied at a minimum of one-week intervals, for up to a maximum of four applications in 12 weeks, when there is evidence of wound healing.
- j. Kerecis® is limited to one application per calendar week, for a maximum of
12 weeks per ulcer.
For burn treatments, reimbursement for physician services is limited to the application of the product.
Exclusions
Must be billed in conjunction with codes that describe application of the tissue and preparation of the site. Medicaid also does not cover skin substitutes for infected ulcers; wounds or ulcers progressing toward closure with traditional wound care; eschar or necrotic material; ulcers with sinus tracts or tunnels; underlying osteomyelitis; surrounding cellulitis; known hypersensitivity to substitute materials; arterial disease with ABI less than 0.70 or lack of pedal pulses; uncontrolled diabetes; active Charcot's arthropathy of the ulcer extremity; vasculitis; uncontrolled rheumatoid arthritis or rheumatoid ulcers; other uncontrolled collagen vascular diseases; treatment with high-dose corticosteroids or immunosuppressants; or radiation or chemotherapy within the month immediately preceding proposed treatment.
Place of Service
Place of service for Dermagraft® Apligraf®, EpiFix®, TheraSkin®, GrafixCore®, GrafixPrime®, Allopatch®, Amnioband® and Kerecis® is limited to inpatient, outpatient hospital, and office.
Place of service for Integra® and AlloDerm® is limited to inpatient and outpatient hospital.
How to Submit
N/A - No authorization is required
Resources
Skin Substitutes
Skin substitutes are used to treat chronic wounds, burns, rare skin conditions, trauma, ischemia, or other neurological impairments; over 90 percent of the lesions are related to venous stasis disease and diabetic neuropathy. These products promote the growth of new skin or serve as a temporary cover until other grafts can be placed. The addition of Skin Substitutes, Cellular or Tissue Based Products (CTPs) to certain wounds may afford a healing advantage over dressings and conservative treatments when these options appear insufficient to affect complete healing. There are currently a wide variety of bioengineered products available for soft tissue coverage to affect closure. These products may be derived from human tissue (allogeneic or autologous), non-human tissue (xenogeneic), synthetic sources or a combination of any or all these types of materials. However, without the component of the recipient’s own distinct epithelium and cellular skin elements, permanent skin replacement or coverage by graft cannot be accomplished.
Authorization Guidelines
Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
Unit Value
One unit equals 1 square centimeter
Limits
.a. Apligraf® is limited to 176 units within 180 calendar days, with no more than four applications per ulcer.
- b. GrafixPrime® is limited to one application per calendar week, for a maximum
of 12 weeks per ulcer.
- c. GrafixCore® is limited to one application per calendar week, for a maximum
of 12 weeks per ulcer.
- d. Amnioband® is limited to one application per seven calendar days, for a
maximum of 12 weeks per ulcer.
- e. Dermagraft®is limited to 304 units within 12 weeks, with no more than 8
applications per ulcer.
- f. Allopatch is limited to one application per seven calendar days for a
maximum of 12 weeks per ulcer.
- g. TheraSkin® is limited to eight applications per ulcer. Each application is
limited to 80 units per day, to a maximum of 640 units every 12 weeks. Reapplication of TheraSkin® within one week for the same ulcer is not allowed.
Re-application of TheraSkin® is not allowed for the same ulcer if satisfactory and reasonable healing progress is not noted after 12 weeks of therapy.
- h. Integra® coverage is limited to the application of a quantity of material that
closely approximates the size of the wound. The number of units billed must closely correlate with the wound size. The maximum daily allowable units are 60.
- i. EpiFix® is limited to ten applications per ulcer; the initial application, then
additional applications may be applied at a minimum of one-week intervals, for up to a maximum of four applications in 12 weeks, when there is evidence of wound healing.
- j. Kerecis® is limited to one application per calendar week, for a maximum of
12 weeks per ulcer.
For burn treatments, reimbursement for physician services is limited to the application of the product.
Exclusions
Must be billed in conjunction with codes that describe application of the tissue and preparation of the site. Medicaid also does not cover skin substitutes for infected ulcers; wounds or ulcers progressing toward closure with traditional wound care; eschar or necrotic material; ulcers with sinus tracts or tunnels; underlying osteomyelitis; surrounding cellulitis; known hypersensitivity to substitute materials; arterial disease with ABI less than 0.70 or lack of pedal pulses; uncontrolled diabetes; active Charcot's arthropathy of the ulcer extremity; vasculitis; uncontrolled rheumatoid arthritis or rheumatoid ulcers; other uncontrolled collagen vascular diseases; treatment with high-dose corticosteroids or immunosuppressants; or radiation or chemotherapy within the month immediately preceding proposed treatment.
Place of Service
Place of service for Dermagraft® Apligraf®, EpiFix®, TheraSkin®, GrafixCore®, GrafixPrime®, Allopatch®, Amnioband® and Kerecis® is limited to inpatient, outpatient hospital, and office.
Place of service for Integra® and AlloDerm® is limited to inpatient and outpatient hospital.
How to Submit
N/A - No authorization is required
Resources
Skin Substitutes
Skin substitutes are used to treat chronic wounds, burns, rare skin conditions, trauma, ischemia, or other neurological impairments; over 90 percent of the lesions are related to venous stasis disease and diabetic neuropathy. These products promote the growth of new skin or serve as a temporary cover until other grafts can be placed. The addition of Skin Substitutes, Cellular or Tissue Based Products (CTPs) to certain wounds may afford a healing advantage over dressings and conservative treatments when these options appear insufficient to affect complete healing. There are currently a wide variety of bioengineered products available for soft tissue coverage to affect closure. These products may be derived from human tissue (allogeneic or autologous), non-human tissue (xenogeneic), synthetic sources or a combination of any or all these types of materials. However, without the component of the recipient’s own distinct epithelium and cellular skin elements, permanent skin replacement or coverage by graft cannot be accomplished.
Authorization Guidelines
Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
Unit Value
One unit equals 1 square centimeter
Limits
.a. Apligraf® is limited to 176 units within 180 calendar days, with no more than four applications per ulcer.
- b. GrafixPrime® is limited to one application per calendar week, for a maximum
of 12 weeks per ulcer.
- c. GrafixCore® is limited to one application per calendar week, for a maximum
of 12 weeks per ulcer.
- d. Amnioband® is limited to one application per seven calendar days, for a
maximum of 12 weeks per ulcer.
- e. Dermagraft®is limited to 304 units within 12 weeks, with no more than 8
applications per ulcer.
- f. Allopatch is limited to one application per seven calendar days for a
maximum of 12 weeks per ulcer.
- g. TheraSkin® is limited to eight applications per ulcer. Each application is
limited to 80 units per day, to a maximum of 640 units every 12 weeks. Reapplication of TheraSkin® within one week for the same ulcer is not allowed.
Re-application of TheraSkin® is not allowed for the same ulcer if satisfactory and reasonable healing progress is not noted after 12 weeks of therapy.
- h. Integra® coverage is limited to the application of a quantity of material that
closely approximates the size of the wound. The number of units billed must closely correlate with the wound size. The maximum daily allowable units are 60.
- i. EpiFix® is limited to ten applications per ulcer; the initial application, then
additional applications may be applied at a minimum of one-week intervals, for up to a maximum of four applications in 12 weeks, when there is evidence of wound healing.
- j. Kerecis® is limited to one application per calendar week, for a maximum of
12 weeks per ulcer.
For burn treatments, reimbursement for physician services is limited to the application of the product.
Exclusions
Must be billed in conjunction with codes that describe application of the tissue and preparation of the site. Medicaid also does not cover skin substitutes for infected ulcers; wounds or ulcers progressing toward closure with traditional wound care; eschar or necrotic material; ulcers with sinus tracts or tunnels; underlying osteomyelitis; surrounding cellulitis; known hypersensitivity to substitute materials; arterial disease with ABI less than 0.70 or lack of pedal pulses; uncontrolled diabetes; active Charcot's arthropathy of the ulcer extremity; vasculitis; uncontrolled rheumatoid arthritis or rheumatoid ulcers; other uncontrolled collagen vascular diseases; treatment with high-dose corticosteroids or immunosuppressants; or radiation or chemotherapy within the month immediately preceding proposed treatment.
Place of Service
Place of service for Dermagraft® Apligraf®, EpiFix®, TheraSkin®, GrafixCore®, GrafixPrime®, Allopatch®, Amnioband® and Kerecis® is limited to inpatient, outpatient hospital, and office.
Place of service for Integra® and AlloDerm® is limited to inpatient and outpatient hospital.
How to Submit
N/A - No authorization is required
Resources
Skin Substitutes
Skin substitutes are used to treat chronic wounds, burns, rare skin conditions, trauma, ischemia, or other neurological impairments; over 90 percent of the lesions are related to venous stasis disease and diabetic neuropathy. These products promote the growth of new skin or serve as a temporary cover until other grafts can be placed. The addition of Skin Substitutes, Cellular or Tissue Based Products (CTPs) to certain wounds may afford a healing advantage over dressings and conservative treatments when these options appear insufficient to affect complete healing. There are currently a wide variety of bioengineered products available for soft tissue coverage to affect closure. These products may be derived from human tissue (allogeneic or autologous), non-human tissue (xenogeneic), synthetic sources or a combination of any or all these types of materials. However, without the component of the recipient’s own distinct epithelium and cellular skin elements, permanent skin replacement or coverage by graft cannot be accomplished.
Authorization Guidelines
Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
Unit Value
One unit equals 1 square centimeter
Limits
.a. Apligraf® is limited to 176 units within 180 calendar days, with no more than four applications per ulcer.
- b. GrafixPrime® is limited to one application per calendar week, for a maximum
of 12 weeks per ulcer.
- c. GrafixCore® is limited to one application per calendar week, for a maximum
of 12 weeks per ulcer.
- d. Amnioband® is limited to one application per seven calendar days, for a
maximum of 12 weeks per ulcer.
- e. Dermagraft®is limited to 304 units within 12 weeks, with no more than 8
applications per ulcer.
- f. Allopatch is limited to one application per seven calendar days for a
maximum of 12 weeks per ulcer.
- g. TheraSkin® is limited to eight applications per ulcer. Each application is
limited to 80 units per day, to a maximum of 640 units every 12 weeks. Reapplication of TheraSkin® within one week for the same ulcer is not allowed.
Re-application of TheraSkin® is not allowed for the same ulcer if satisfactory and reasonable healing progress is not noted after 12 weeks of therapy.
- h. Integra® coverage is limited to the application of a quantity of material that
closely approximates the size of the wound. The number of units billed must closely correlate with the wound size. The maximum daily allowable units are 60.
- i. EpiFix® is limited to ten applications per ulcer; the initial application, then
additional applications may be applied at a minimum of one-week intervals, for up to a maximum of four applications in 12 weeks, when there is evidence of wound healing.
- j. Kerecis® is limited to one application per calendar week, for a maximum of
12 weeks per ulcer.
For burn treatments, reimbursement for physician services is limited to the application of the product.
Exclusions
Must be billed in conjunction with codes that describe application of the tissue and preparation of the site. Medicaid also does not cover skin substitutes for infected ulcers; wounds or ulcers progressing toward closure with traditional wound care; eschar or necrotic material; ulcers with sinus tracts or tunnels; underlying osteomyelitis; surrounding cellulitis; known hypersensitivity to substitute materials; arterial disease with ABI less than 0.70 or lack of pedal pulses; uncontrolled diabetes; active Charcot's arthropathy of the ulcer extremity; vasculitis; uncontrolled rheumatoid arthritis or rheumatoid ulcers; other uncontrolled collagen vascular diseases; treatment with high-dose corticosteroids or immunosuppressants; or radiation or chemotherapy within the month immediately preceding proposed treatment.
Place of Service
Place of service for Dermagraft® Apligraf®, EpiFix®, TheraSkin®, GrafixCore®, GrafixPrime®, Allopatch®, Amnioband® and Kerecis® is limited to inpatient, outpatient hospital, and office.
Place of service for Integra® and AlloDerm® is limited to inpatient and outpatient hospital.
How to Submit
N/A - No authorization is required
Resources
Skin Substitutes
Skin substitutes are used to treat chronic wounds, burns, rare skin conditions, trauma, ischemia, or other neurological impairments; over 90 percent of the lesions are related to venous stasis disease and diabetic neuropathy. These products promote the growth of new skin or serve as a temporary cover until other grafts can be placed. The addition of Skin Substitutes, Cellular or Tissue Based Products (CTPs) to certain wounds may afford a healing advantage over dressings and conservative treatments when these options appear insufficient to affect complete healing. There are currently a wide variety of bioengineered products available for soft tissue coverage to affect closure. These products may be derived from human tissue (allogeneic or autologous), non-human tissue (xenogeneic), synthetic sources or a combination of any or all these types of materials. However, without the component of the recipient’s own distinct epithelium and cellular skin elements, permanent skin replacement or coverage by graft cannot be accomplished.
Authorization Guidelines
Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
Unit Value
One unit equals 1 square centimeter
Limits
.a. Apligraf® is limited to 176 units within 180 calendar days, with no more than four applications per ulcer.
- b. GrafixPrime® is limited to one application per calendar week, for a maximum
of 12 weeks per ulcer.
- c. GrafixCore® is limited to one application per calendar week, for a maximum
of 12 weeks per ulcer.
- d. Amnioband® is limited to one application per seven calendar days, for a
maximum of 12 weeks per ulcer.
- e. Dermagraft®is limited to 304 units within 12 weeks, with no more than 8
applications per ulcer.
- f. Allopatch is limited to one application per seven calendar days for a
maximum of 12 weeks per ulcer.
- g. TheraSkin® is limited to eight applications per ulcer. Each application is
limited to 80 units per day, to a maximum of 640 units every 12 weeks. Reapplication of TheraSkin® within one week for the same ulcer is not allowed.
Re-application of TheraSkin® is not allowed for the same ulcer if satisfactory and reasonable healing progress is not noted after 12 weeks of therapy.
- h. Integra® coverage is limited to the application of a quantity of material that
closely approximates the size of the wound. The number of units billed must closely correlate with the wound size. The maximum daily allowable units are 60.
- i. EpiFix® is limited to ten applications per ulcer; the initial application, then
additional applications may be applied at a minimum of one-week intervals, for up to a maximum of four applications in 12 weeks, when there is evidence of wound healing.
- j. Kerecis® is limited to one application per calendar week, for a maximum of
12 weeks per ulcer.
For burn treatments, reimbursement for physician services is limited to the application of the product.
Exclusions
Must be billed in conjunction with codes that describe application of the tissue and preparation of the site. Medicaid also does not cover skin substitutes for infected ulcers; wounds or ulcers progressing toward closure with traditional wound care; eschar or necrotic material; ulcers with sinus tracts or tunnels; underlying osteomyelitis; surrounding cellulitis; known hypersensitivity to substitute materials; arterial disease with ABI less than 0.70 or lack of pedal pulses; uncontrolled diabetes; active Charcot's arthropathy of the ulcer extremity; vasculitis; uncontrolled rheumatoid arthritis or rheumatoid ulcers; other uncontrolled collagen vascular diseases; treatment with high-dose corticosteroids or immunosuppressants; or radiation or chemotherapy within the month immediately preceding proposed treatment.
Place of Service
Place of service for Dermagraft® Apligraf®, EpiFix®, TheraSkin®, GrafixCore®, GrafixPrime®, Allopatch®, Amnioband® and Kerecis® is limited to inpatient, outpatient hospital, and office.
Place of service for Integra® and AlloDerm® is limited to inpatient and outpatient hospital.
How to Submit
N/A - No authorization is required
Resources
Skin Substitutes
Skin substitutes are used to treat chronic wounds, burns, rare skin conditions, trauma, ischemia, or other neurological impairments; over 90 percent of the lesions are related to venous stasis disease and diabetic neuropathy. These products promote the growth of new skin or serve as a temporary cover until other grafts can be placed. The addition of Skin Substitutes, Cellular or Tissue Based Products (CTPs) to certain wounds may afford a healing advantage over dressings and conservative treatments when these options appear insufficient to affect complete healing. There are currently a wide variety of bioengineered products available for soft tissue coverage to affect closure. These products may be derived from human tissue (allogeneic or autologous), non-human tissue (xenogeneic), synthetic sources or a combination of any or all these types of materials. However, without the component of the recipient’s own distinct epithelium and cellular skin elements, permanent skin replacement or coverage by graft cannot be accomplished.
Authorization Guidelines
Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
Unit Value
One unit equals 1 square centimeter
Limits
.a. Apligraf® is limited to 176 units within 180 calendar days, with no more than four applications per ulcer.
- b. GrafixPrime® is limited to one application per calendar week, for a maximum
of 12 weeks per ulcer.
- c. GrafixCore® is limited to one application per calendar week, for a maximum
of 12 weeks per ulcer.
- d. Amnioband® is limited to one application per seven calendar days, for a
maximum of 12 weeks per ulcer.
- e. Dermagraft®is limited to 304 units within 12 weeks, with no more than 8
applications per ulcer.
- f. Allopatch is limited to one application per seven calendar days for a
maximum of 12 weeks per ulcer.
- g. TheraSkin® is limited to eight applications per ulcer. Each application is
limited to 80 units per day, to a maximum of 640 units every 12 weeks. Reapplication of TheraSkin® within one week for the same ulcer is not allowed.
Re-application of TheraSkin® is not allowed for the same ulcer if satisfactory and reasonable healing progress is not noted after 12 weeks of therapy.
- h. Integra® coverage is limited to the application of a quantity of material that
closely approximates the size of the wound. The number of units billed must closely correlate with the wound size. The maximum daily allowable units are 60.
- i. EpiFix® is limited to ten applications per ulcer; the initial application, then
additional applications may be applied at a minimum of one-week intervals, for up to a maximum of four applications in 12 weeks, when there is evidence of wound healing.
- j. Kerecis® is limited to one application per calendar week, for a maximum of
12 weeks per ulcer.
For burn treatments, reimbursement for physician services is limited to the application of the product.
Exclusions
Must be billed in conjunction with codes that describe application of the tissue and preparation of the site. Medicaid also does not cover skin substitutes for infected ulcers; wounds or ulcers progressing toward closure with traditional wound care; eschar or necrotic material; ulcers with sinus tracts or tunnels; underlying osteomyelitis; surrounding cellulitis; known hypersensitivity to substitute materials; arterial disease with ABI less than 0.70 or lack of pedal pulses; uncontrolled diabetes; active Charcot's arthropathy of the ulcer extremity; vasculitis; uncontrolled rheumatoid arthritis or rheumatoid ulcers; other uncontrolled collagen vascular diseases; treatment with high-dose corticosteroids or immunosuppressants; or radiation or chemotherapy within the month immediately preceding proposed treatment.
Place of Service
Place of service for Dermagraft® Apligraf®, EpiFix®, TheraSkin®, GrafixCore®, GrafixPrime®, Allopatch®, Amnioband® and Kerecis® is limited to inpatient, outpatient hospital, and office.
Place of service for Integra® and AlloDerm® is limited to inpatient and outpatient hospital.
How to Submit
N/A - No authorization is required
Resources
Skin Substitutes
Skin substitutes are used to treat chronic wounds, burns, rare skin conditions, trauma, ischemia, or other neurological impairments; over 90 percent of the lesions are related to venous stasis disease and diabetic neuropathy. These products promote the growth of new skin or serve as a temporary cover until other grafts can be placed. The addition of Skin Substitutes, Cellular or Tissue Based Products (CTPs) to certain wounds may afford a healing advantage over dressings and conservative treatments when these options appear insufficient to affect complete healing. There are currently a wide variety of bioengineered products available for soft tissue coverage to affect closure. These products may be derived from human tissue (allogeneic or autologous), non-human tissue (xenogeneic), synthetic sources or a combination of any or all these types of materials. However, without the component of the recipient’s own distinct epithelium and cellular skin elements, permanent skin replacement or coverage by graft cannot be accomplished.
Authorization Guidelines
Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
Unit Value
One unit equals 1 square centimeter
Limits
.a. Apligraf® is limited to 176 units within 180 calendar days, with no more than four applications per ulcer.
- b. GrafixPrime® is limited to one application per calendar week, for a maximum
of 12 weeks per ulcer.
- c. GrafixCore® is limited to one application per calendar week, for a maximum
of 12 weeks per ulcer.
- d. Amnioband® is limited to one application per seven calendar days, for a
maximum of 12 weeks per ulcer.
- e. Dermagraft®is limited to 304 units within 12 weeks, with no more than 8
applications per ulcer.
- f. Allopatch is limited to one application per seven calendar days for a
maximum of 12 weeks per ulcer.
- g. TheraSkin® is limited to eight applications per ulcer. Each application is
limited to 80 units per day, to a maximum of 640 units every 12 weeks. Reapplication of TheraSkin® within one week for the same ulcer is not allowed.
Re-application of TheraSkin® is not allowed for the same ulcer if satisfactory and reasonable healing progress is not noted after 12 weeks of therapy.
- h. Integra® coverage is limited to the application of a quantity of material that
closely approximates the size of the wound. The number of units billed must closely correlate with the wound size. The maximum daily allowable units are 60.
- i. EpiFix® is limited to ten applications per ulcer; the initial application, then
additional applications may be applied at a minimum of one-week intervals, for up to a maximum of four applications in 12 weeks, when there is evidence of wound healing.
- j. Kerecis® is limited to one application per calendar week, for a maximum of
12 weeks per ulcer.
For burn treatments, reimbursement for physician services is limited to the application of the product.
Exclusions
Must be billed in conjunction with codes that describe application of the tissue and preparation of the site. Medicaid also does not cover skin substitutes for infected ulcers; wounds or ulcers progressing toward closure with traditional wound care; eschar or necrotic material; ulcers with sinus tracts or tunnels; underlying osteomyelitis; surrounding cellulitis; known hypersensitivity to substitute materials; arterial disease with ABI less than 0.70 or lack of pedal pulses; uncontrolled diabetes; active Charcot's arthropathy of the ulcer extremity; vasculitis; uncontrolled rheumatoid arthritis or rheumatoid ulcers; other uncontrolled collagen vascular diseases; treatment with high-dose corticosteroids or immunosuppressants; or radiation or chemotherapy within the month immediately preceding proposed treatment.
Place of Service
Place of service for Dermagraft® Apligraf®, EpiFix®, TheraSkin®, GrafixCore®, GrafixPrime®, Allopatch®, Amnioband® and Kerecis® is limited to inpatient, outpatient hospital, and office.
Place of service for Integra® and AlloDerm® is limited to inpatient and outpatient hospital.
How to Submit
N/A - No authorization is required
Resources
Skin Substitutes
Skin substitutes are used to treat chronic wounds, burns, rare skin conditions, trauma, ischemia, or other neurological impairments; over 90 percent of the lesions are related to venous stasis disease and diabetic neuropathy. These products promote the growth of new skin or serve as a temporary cover until other grafts can be placed. The addition of Skin Substitutes, Cellular or Tissue Based Products (CTPs) to certain wounds may afford a healing advantage over dressings and conservative treatments when these options appear insufficient to affect complete healing. There are currently a wide variety of bioengineered products available for soft tissue coverage to affect closure. These products may be derived from human tissue (allogeneic or autologous), non-human tissue (xenogeneic), synthetic sources or a combination of any or all these types of materials. However, without the component of the recipient’s own distinct epithelium and cellular skin elements, permanent skin replacement or coverage by graft cannot be accomplished.
Authorization Guidelines
Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
Unit Value
One unit equals 1 square centimeter
Limits
.a. Apligraf® is limited to 176 units within 180 calendar days, with no more than four applications per ulcer.
- b. GrafixPrime® is limited to one application per calendar week, for a maximum
of 12 weeks per ulcer.
- c. GrafixCore® is limited to one application per calendar week, for a maximum
of 12 weeks per ulcer.
- d. Amnioband® is limited to one application per seven calendar days, for a
maximum of 12 weeks per ulcer.
- e. Dermagraft®is limited to 304 units within 12 weeks, with no more than 8
applications per ulcer.
- f. Allopatch is limited to one application per seven calendar days for a
maximum of 12 weeks per ulcer.
- g. TheraSkin® is limited to eight applications per ulcer. Each application is
limited to 80 units per day, to a maximum of 640 units every 12 weeks. Reapplication of TheraSkin® within one week for the same ulcer is not allowed.
Re-application of TheraSkin® is not allowed for the same ulcer if satisfactory and reasonable healing progress is not noted after 12 weeks of therapy.
- h. Integra® coverage is limited to the application of a quantity of material that
closely approximates the size of the wound. The number of units billed must closely correlate with the wound size. The maximum daily allowable units are 60.
- i. EpiFix® is limited to ten applications per ulcer; the initial application, then
additional applications may be applied at a minimum of one-week intervals, for up to a maximum of four applications in 12 weeks, when there is evidence of wound healing.
- j. Kerecis® is limited to one application per calendar week, for a maximum of
12 weeks per ulcer.
For burn treatments, reimbursement for physician services is limited to the application of the product.
Exclusions
Must be billed in conjunction with codes that describe application of the tissue and preparation of the site. Medicaid also does not cover skin substitutes for infected ulcers; wounds or ulcers progressing toward closure with traditional wound care; eschar or necrotic material; ulcers with sinus tracts or tunnels; underlying osteomyelitis; surrounding cellulitis; known hypersensitivity to substitute materials; arterial disease with ABI less than 0.70 or lack of pedal pulses; uncontrolled diabetes; active Charcot's arthropathy of the ulcer extremity; vasculitis; uncontrolled rheumatoid arthritis or rheumatoid ulcers; other uncontrolled collagen vascular diseases; treatment with high-dose corticosteroids or immunosuppressants; or radiation or chemotherapy within the month immediately preceding proposed treatment.
Place of Service
Place of service for Dermagraft® Apligraf®, EpiFix®, TheraSkin®, GrafixCore®, GrafixPrime®, Allopatch®, Amnioband® and Kerecis® is limited to inpatient, outpatient hospital, and office.
Place of service for Integra® and AlloDerm® is limited to inpatient and outpatient hospital.
How to Submit
N/A - No authorization is required
Resources
Skin Substitutes
Skin substitutes are used to treat chronic wounds, burns, rare skin conditions, trauma, ischemia, or other neurological impairments; over 90 percent of the lesions are related to venous stasis disease and diabetic neuropathy. These products promote the growth of new skin or serve as a temporary cover until other grafts can be placed. The addition of Skin Substitutes, Cellular or Tissue Based Products (CTPs) to certain wounds may afford a healing advantage over dressings and conservative treatments when these options appear insufficient to affect complete healing. There are currently a wide variety of bioengineered products available for soft tissue coverage to affect closure. These products may be derived from human tissue (allogeneic or autologous), non-human tissue (xenogeneic), synthetic sources or a combination of any or all these types of materials. However, without the component of the recipient’s own distinct epithelium and cellular skin elements, permanent skin replacement or coverage by graft cannot be accomplished.
Authorization Guidelines
Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
Unit Value
One unit equals 1 square centimeter
Limits
.a. Apligraf® is limited to 176 units within 180 calendar days, with no more than four applications per ulcer.
- b. GrafixPrime® is limited to one application per calendar week, for a maximum
of 12 weeks per ulcer.
- c. GrafixCore® is limited to one application per calendar week, for a maximum
of 12 weeks per ulcer.
- d. Amnioband® is limited to one application per seven calendar days, for a
maximum of 12 weeks per ulcer.
- e. Dermagraft®is limited to 304 units within 12 weeks, with no more than 8
applications per ulcer.
- f. Allopatch is limited to one application per seven calendar days for a
maximum of 12 weeks per ulcer.
- g. TheraSkin® is limited to eight applications per ulcer. Each application is
limited to 80 units per day, to a maximum of 640 units every 12 weeks. Reapplication of TheraSkin® within one week for the same ulcer is not allowed.
Re-application of TheraSkin® is not allowed for the same ulcer if satisfactory and reasonable healing progress is not noted after 12 weeks of therapy.
- h. Integra® coverage is limited to the application of a quantity of material that
closely approximates the size of the wound. The number of units billed must closely correlate with the wound size. The maximum daily allowable units are 60.
- i. EpiFix® is limited to ten applications per ulcer; the initial application, then
additional applications may be applied at a minimum of one-week intervals, for up to a maximum of four applications in 12 weeks, when there is evidence of wound healing.
- j. Kerecis® is limited to one application per calendar week, for a maximum of
12 weeks per ulcer.
For burn treatments, reimbursement for physician services is limited to the application of the product.
Exclusions
Must be billed in conjunction with codes that describe application of the tissue and preparation of the site. Medicaid also does not cover skin substitutes for infected ulcers; wounds or ulcers progressing toward closure with traditional wound care; eschar or necrotic material; ulcers with sinus tracts or tunnels; underlying osteomyelitis; surrounding cellulitis; known hypersensitivity to substitute materials; arterial disease with ABI less than 0.70 or lack of pedal pulses; uncontrolled diabetes; active Charcot's arthropathy of the ulcer extremity; vasculitis; uncontrolled rheumatoid arthritis or rheumatoid ulcers; other uncontrolled collagen vascular diseases; treatment with high-dose corticosteroids or immunosuppressants; or radiation or chemotherapy within the month immediately preceding proposed treatment.
Place of Service
Place of service for Dermagraft® Apligraf®, EpiFix®, TheraSkin®, GrafixCore®, GrafixPrime®, Allopatch®, Amnioband® and Kerecis® is limited to inpatient, outpatient hospital, and office.
Place of service for Integra® and AlloDerm® is limited to inpatient and outpatient hospital.
How to Submit
N/A - No authorization is required
Resources
Skin Substitutes
Skin substitutes are used to treat chronic wounds, burns, rare skin conditions, trauma, ischemia, or other neurological impairments; over 90 percent of the lesions are related to venous stasis disease and diabetic neuropathy. These products promote the growth of new skin or serve as a temporary cover until other grafts can be placed. The addition of Skin Substitutes, Cellular or Tissue Based Products (CTPs) to certain wounds may afford a healing advantage over dressings and conservative treatments when these options appear insufficient to affect complete healing. There are currently a wide variety of bioengineered products available for soft tissue coverage to affect closure. These products may be derived from human tissue (allogeneic or autologous), non-human tissue (xenogeneic), synthetic sources or a combination of any or all these types of materials. However, without the component of the recipient’s own distinct epithelium and cellular skin elements, permanent skin replacement or coverage by graft cannot be accomplished.
Authorization Guidelines
Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
Unit Value
One unit equals 1 square centimeter
Limits
.a. Apligraf® is limited to 176 units within 180 calendar days, with no more than four applications per ulcer.
- b. GrafixPrime® is limited to one application per calendar week, for a maximum
of 12 weeks per ulcer.
- c. GrafixCore® is limited to one application per calendar week, for a maximum
of 12 weeks per ulcer.
- d. Amnioband® is limited to one application per seven calendar days, for a
maximum of 12 weeks per ulcer.
- e. Dermagraft®is limited to 304 units within 12 weeks, with no more than 8
applications per ulcer.
- f. Allopatch is limited to one application per seven calendar days for a
maximum of 12 weeks per ulcer.
- g. TheraSkin® is limited to eight applications per ulcer. Each application is
limited to 80 units per day, to a maximum of 640 units every 12 weeks. Reapplication of TheraSkin® within one week for the same ulcer is not allowed.
Re-application of TheraSkin® is not allowed for the same ulcer if satisfactory and reasonable healing progress is not noted after 12 weeks of therapy.
- h. Integra® coverage is limited to the application of a quantity of material that
closely approximates the size of the wound. The number of units billed must closely correlate with the wound size. The maximum daily allowable units are 60.
- i. EpiFix® is limited to ten applications per ulcer; the initial application, then
additional applications may be applied at a minimum of one-week intervals, for up to a maximum of four applications in 12 weeks, when there is evidence of wound healing.
- j. Kerecis® is limited to one application per calendar week, for a maximum of
12 weeks per ulcer.
For burn treatments, reimbursement for physician services is limited to the application of the product.
Exclusions
Must be billed in conjunction with codes that describe application of the tissue and preparation of the site. Medicaid also does not cover skin substitutes for infected ulcers; wounds or ulcers progressing toward closure with traditional wound care; eschar or necrotic material; ulcers with sinus tracts or tunnels; underlying osteomyelitis; surrounding cellulitis; known hypersensitivity to substitute materials; arterial disease with ABI less than 0.70 or lack of pedal pulses; uncontrolled diabetes; active Charcot's arthropathy of the ulcer extremity; vasculitis; uncontrolled rheumatoid arthritis or rheumatoid ulcers; other uncontrolled collagen vascular diseases; treatment with high-dose corticosteroids or immunosuppressants; or radiation or chemotherapy within the month immediately preceding proposed treatment.
Place of Service
Place of service for Dermagraft® Apligraf®, EpiFix®, TheraSkin®, GrafixCore®, GrafixPrime®, Allopatch®, Amnioband® and Kerecis® is limited to inpatient, outpatient hospital, and office.
Place of service for Integra® and AlloDerm® is limited to inpatient and outpatient hospital.
How to Submit
N/A - No authorization is required
Resources
Membrane Graft or Membrane Wrap, per sq cm
Authorization Guidelines
Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
How to Submit
N/A - No authorization is required
Fluid Flow or Fluid GF, 1 cc
Authorization Guidelines
Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
How to Submit
N/A - No authorization is required
Novafix, per sq cm
Authorization Guidelines
Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
How to Submit
N/A - No authorization is required
SurGraft, per sq cm
Authorization Guidelines
Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
How to Submit
N/A - No authorization is required
Amnion Bio or AxoBioMembrane, per sq cm
Authorization Guidelines
Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
How to Submit
N/A - No authorization is required
AlloGen, per cc
Authorization Guidelines
Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
How to Submit
N/A - No authorization is required
Ascent, 0.5 mg
Authorization Guidelines
Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
How to Submit
N/A - No authorization is required
Cellesta Cord, per sq cm
Authorization Guidelines
Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
How to Submit
N/A - No authorization is required
If you find any wrong or out of date information on our pages, we want to know. Please email info@TrilliumNC.org with any corrections.