Are the Dressings I Need Covered?

When a patient has wounds, the costs of the dressings to manage and heal the wound can quickly add up. Costs should never be a factor in caring for a patient; fortunately Medicare can often take up the burden of paying for those supplies.

Many wound dressings are covered by Medicare part B and don’t need to be paid for out of pocket by the patient or their LTC.
However, Medicare has strict rules regarding coverage for most types of dressings, and it can often be confusing which dressing to choose.

Often, there may be multiple ways to successfully manage and guide a wound towards successful resolution, but not all options are necessarily covered. 
Here is an easy-to-understand guide, taken from the Medicare LCD for Surgical Dressings, outlining when the various dressings are considered “reasonable and necessary”, and thereby covered.

You can download here our handy reference card that lists the most common dressings, what category they fall under, and the basic coverage requirements for each dressing type.
The full LCD can be viewed here.

Disclaimer: Always follow your healthcare provider’s recommendations. The following is not intended to be a guide to treatment, but to inform you in what cases Medicare part B coverage would cover the costs of the supplies.

First and foremost – for any wound to be covered it must either be a surgical wound or, at some point, have been debrided. 

Any form of debridement (surgical, chemical, mechanical, or autolytic) will qualify a wound for coverage. Additionally, if the current treatment involves debridement, then the dressings used for the debridement are also covered, although the debriding agents (e.g., Santyl) are themselves not covered.

Below is a list of dressings and what they are covered for:

• Alginate or other fiber gelling wound cover sheets and fillers:
  • Moderately to highly exudative full thickness wounds (e.g., stage III or IV ulcers).
  • Fillers are covered for moderately to highly exudative full thickness wound cavities.
  • Not covered on dry wounds or wounds covered with eschar. Dressing change is covered up to once per day.  
    
• Collagen-based dressings or wound fillers:
  • Full thickness wounds (e.g., stage III or IV ulcers) with light to moderate exudate.
  • Wounds that have stalled or have not progressed toward a healing goal.
  • Not covered for wounds with heavy exudate, third-degree burns, or when an active vasculitis is present.
• Composite dressings:
  • Moderately to highly exudative wounds.
  • Dressing change is covered up to 3 times per week, one wound cover per dressing change.
• Contact layer dressings:
  • Are not reasonable and necessary when used with any dressing that has a non-adherent or semi-adherent layer as part of the dressing.
  • Dressing change is covered up to once per week.
• Foam dressings:
  • Full thickness wounds (e.g., stage III or IV ulcers) with moderate to heavy exudate.
  • When used as a secondary dressing is only covered for wounds with very heavy exudate.
  • Dressing change is covered up to 3 times per week.
  • Dressing change frequency for foam wound fillers is covered up to once per day.
• Non-impregnated gauze:
  • Dressing change is covered up to 3 times per day for a dressing without a border, or once per day for a dressing with a border.
  • It is usually not reasonable and necessary to stack more than 2 gauze pads on top of each other in any one area.
• Impregnated gauze (with other than water, saline, hydrogel, or zinc paste):
  • Dressing change is covered up to once per day.
• Hydrocolloid dressings:
  • Wounds with light to moderate exudate. Dressing change is covered up to 3 times per week.
• Hydrogel dressings: 
  • Full thickness wounds (e.g., stage III or IV ulcers) with minimal or no exudate are not covered for stage II ulcers.
  • Dressing change is covered up to once per day for wound covers without adhesive border or wound filler.
  • Dressing change for wound covers with an adhesive border is covered up to 3 times per week.
  • The quantity of hydrogel filler used for each wound must not exceed the amount needed to line the surface of the wound.
  • Maximum utilization is 3 fluid ounces per wound in 30 days.
  • Use of more than one type of hydrogel dressing (filler, cover, or impregnated gauze) on the same wound at the same time is not covered.
• Specialty absorptive dressings:
  • Moderately or highly exudative full thickness wounds (e.g., stage III or IV ulcers).
  • Dressing change is covered up to once per day for a dressing without an adhesive border, or up to every other day for a dressing with a border.
• Transparent film dressings: 
  • Open partial thickness wounds with minimal exudate or closed wounds.
  • Dressing change is covered up to 3 times per week.
• Zinc paste impregnated bandages:
  • Venous leg ulcers that have been surgically created or modified, or debrided.
  • Dressing change frequency is weekly.

Any Questions?

Our friendly and knowledgeable team will be happy to answer your questions. Contact us, and find out more about the Calmed Difference!