Miscellaneous Surgical Dressings - DME.SW.106.A

Evicore covers miscellaneous surgical dressings under HCPCS A4649 only when no specific HCPCS code exists, no single material composes >50% of the dressing, and the dressing is an alginate, collagen, foam, gauze, hydrocolloid, or hydrogel; dressings containing balsam of Peru in castor oil, most iodine preparations (except iodoform gauze packing), charcoal, carbon fiber, copper, honey, or silver are excluded. Required documentation includes evidence of the wound, that no specific HCPCS code applies, the dressing composition showing no predominant material, and clinical rationale for the chosen dressing.

"Covered HCPCS: A4649 (Surgical supply; miscellaneous) when the above criteria are met."

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