August 7, 2023

On August 3, Novitas, First Coast Service Options, and CGS Part B Medicare Administrative Contractors (MAC) finalized skin substitute policies for the treatment of diabetic foot ulcers and venous leg ulcers that become effective September 17.  

All three of these policies state “greater than four applications of a skin substitute graft or CTP within the episode of skin replacement surgery (defined as 12 weeks from the first application of a skin substitute graft or CTP)” are “not medically reasonable and necessary.” Furthermore, all three of these policies list 58 products that meet the necessary FDA regulatory requirements for indications covered in the policy and 130 products that are considered non-covered.

The Novitas Part B Jurisdiction includes AR, CO, DE, LA, MD, MS, NJ, NM, OK, PA, TX, and Washington, DC.

The First Coast Service Options Part B Jurisdiction includes FL, Puerto Rico, and the Virgin Islands.

The CGS Part B Jurisdiction includes KY and OH.

These are final policies. Changes were initially proposed by Novitas and First Coast in April 2022 and by CGS in October 2022. At the time, APMA submitted comments and participated in meetings to provide feedback on these proposals.

The other four Part B MACs have not taken any similar action regarding this service. To get the latest coding news and updates, visit www.apma.org/coding.

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