CG-SURG-127 Products for Wound Healing and Soft Tissue Grafting: Medically Necessary Uses

This policy addresses biologic/synthetic products for wound healing and soft tissue grafting (e.g., acellular dermal matrices) used in surgical reconstruction and wound care. Coverage is product- and indication-specific: for breast reconstruction, AlloDerm Regenerative Tissue Matrix (aseptic or sterile), Cortiva, DermACELL, or DermaMatrix are medically necessary; any other product for breast reconstruction—or for burns, complex abdominal wall reconstruction, diabetic foot ulcers, dystrophic epidermolysis bullosa, non-healing wounds, or ocular indications—is not medically necessary unless explicitly listed for that indication in the policy, and Stravix/StravixPL are not medically necessary for any use.

"The following products are consideredmedically necessarywhen used for breast reconstruction surgery:"

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