Skin Substitute Grafts/Cellular and Tissue-Based Products for the Treatment of Diabetic Foot Ulcers and Venous Leg Ulcers
L39764
Covered: Sheet-form skin substitute grafts/CTPs with supporting evidence are covered as adjuncts to standard-of-care for chronic DFUs and VLUs that have failed to achieve ≥50% area reduction after ≥4 weeks of documented SOC; liquid/gel preparations, certain listed products/variants, and use in actively infected, ischemic, necrotic, or otherwise contraindicated/uncontrolled systemic conditions are excluded. Key requirements: documentation of adequate SOC (debridement, off‑loading for DFU or sustained compression for VLU, infection control), objective perfusion/venous testing and serial wound measurements, product identity and incorporation, continuation of SOC during therapy, a maximum of 8 applications per 12–16 week episode (attestation required if >4 applications).
"Revoshield + amniotic barrier, per sq cm"
Sign up to see full coverage criteria, indications, and limitations.