C1765 — Adhesion barrier
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Documentation that the chlorhexidine-impregnated dressing used is FDA-cleared with a label specifying the clinical indication for reducing catheter-related bloodstream infection (if claiming benefit for CRBSI prevention).
- Clinical documentation of wound type, wound healing intention (primary vs secondary), contamination classification (clean, clean-contaminated, contaminated), and rationale for choosing a specific dressing (e.g., high-exudate wound requiring alginate, painful debridement where EMLA is applied, palliation of fungating wound symptoms).
- For malignant wound cultures: documentation of signs/symptoms of infection (e.g., systemic signs, purulence, spreading cellulitis) to justify wound swabbing and microbiological culture; routine swabbing without signs of infection is discouraged.
Key Coverage Criteria
- Dressings over a percutaneous catheter or tube (e.g., intravascular, epidural, nephrotomy, etc.) are covered as long as the catheter or tube remains in place and after removal until the wound heals.
- CPT codes covered if selection criteria are met: 16020, 16025, 16030, 96574, 97597, 97598, 97602.
- HCPCS codes covered if selection criteria are met include (non-exhaustive as listed in policy): A4450, A4452, A4649, A6025, A6154, A6196–A6199 (alginate), A6200–A6205 (composite), A6206–A6208 (contact layer), A6209–A6215 (foam), A6216–A6221 (gauze nonimpregnated), A6222–A6233 (gauze impregnated), A6234–A6241 (hydrocolloid), A6242–A6248 (hydrogel), A6251–A6256 (specialty absorptive), A6257–A6259 (transparent film), A6261 (wound filler gel/paste), A6262 (wound filler dry form), A6266 (gauze impreg [...]
- ICD-10 codes explicitly listed as covered if selection criteria are met include: pressure ulcer stage III or IV (L89.003–L89.094 and multiple stage III/IV variants listed), non-pressure chronic ulcer stage III or IV (L97.100–L97.929), burns and corrosion of various body regions second or third degree (T20.20x+–T25.* series second/third degree ranges as listed), persistent postprocedural fistula (T81.83x+), open wounds (numerous codes listed/not listed due to specificity).
- Chlorhexidine-impregnated dressings to protect the insertion site of short-term, nontunneled central venous catheters (CVCs) in adults for reduction of catheter colonization and catheter-related bloodstream infection (CRBSI) — supported by RCT meta-analysis and recommended by the CDC when the dressing has an FDA-cleared label specifying this clinical indication.
- Use of 5% eutectic mixture of local anesthetics (EMLA; lidocaine-prilocaine cream) to reduce pain associated with debridement of venous leg ulcers (statistically significant reduction in debridement pain scores reported).
1 Active Policy
AETNA-CPB-0526 — Surgical Dressings (Wound Care Supplies)
Related Codes
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