Amniotic Membrane and Amniotic Fluid

This policy addresses use of human amniotic membrane and select amniotic fluid products for wound and ophthalmic care — most notably nonhealing diabetic lower‑extremity ulcers and specified ocular conditions such as neurotrophic keratitis, persistent epithelial defects, corneal ulcers/perforation, severe dry eye (DEWS 3–4), pterygium repair, limbal stem cell deficiency, Stevens‑Johnson syndrome and palliative bullous keratopathy. Coverage is limited to the specific named membrane products (and non‑FDA‑cleared fluid products identified in the policy), requires documentation of condition‑specific criteria and prior conservative‑therapy failures (eg, <20% wound reduction after ≥2 weeks, ≥2 days failed therapy for persistent epithelial defects, failure of Steps 1–3 for severe dry eye), and considers injections of micronized/particulated membrane or amniotic fluid and other unlisted products/indications experimental/investigational; member benefits and state contract terms govern final coverage.