A6454 — Self-adherent bandage, elastic, non-knitted/non-woven, width greater than or equal to three inches and less than five inches, per yard
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- A Standard Written Order (SWO) must be communicated to the supplier before a claim is submitted; for DMEPOS base items requiring Written Order Prior to Delivery (WOPD) the supplier must have the signed SWO before delivery.
- Proof of delivery (POD) documentation must be maintained by the supplier and made available to the Medicare contractor upon request; lack of POD will result in denial.
- Suppliers must document beneficiary contact and an affirmative refill request prior to dispensing refills; contact must occur no sooner than 30 calendar days before expected end of supply and delivery no sooner than 10 calendar days before expected end of supply.
- Suppliers must monitor and document actual beneficiary utilization and verify with the treating practitioner any changed or atypical utilization patterns before dispensing additional supplies.
Key Coverage Criteria
- Medicare covers surgical dressings that are reasonable and necessary for diagnosis or treatment of illness or injury, for improving function of a malformed body member, and that meet all other Medicare statutory and regulatory requirements.
- Alginate or other fiber gelling dressings (HCPCS A6196-A6199) are covered for moderately to highly exudative full thickness wounds (e.g., stage 3 or 4 ulcers) and for wound cavities, but are not covered for dry wounds or wounds covered with eschar.
- Collagen-based dressings or wound fillers (HCPCS A6010, A6011, A6021-A6024) are covered for full thickness wounds (e.g., stage 3 or 4 ulcers), wounds with light to moderate exudate, or stalled wounds not progressing toward healing.
- Composite dressings (HCPCS A6203-A6205) are covered for moderately to highly exudative wounds.
- Contact layer dressings (HCPCS A6206-A6208) are covered to line the entire wound to prevent adhesion of overlying dressings when the overlying dressing lacks a non-adherent or semi-adherent layer.
- Foam dressings (HCPCS A6209-A6215) are covered for full thickness wounds with moderate to heavy exudate and as secondary dressings for wounds with very heavy exudate.
1 Active Policy
L33831 — Surgical Dressings
J19
Related Codes
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