CommercialDocumentationHigh impact
Burn Garments (CPB 0062, reviewed 2026-01-15)
Aetna·Physical Therapy, Occupational Therapy, Plastic Surgery +3 more·Medical Policy
Effective date
Jan 15, 2026
We identified it
Aug 15, 2026
Summary
Aetna's Burn Garments policy (CPB 0062) establishes new medical necessity criteria and documentation requirements for compression burn garments. Key changes include: (1) all burn garment claims now require a Standard Written Order (SWO) from the treating practitioner before billing, (2) medical records must substantiate all coverage criteria—supplier statements and physician attestations alone are insufficient, and (3) treating practitioners are limited to MDs, DOs, PAs, NPs, and CNSs; therapists cannot authorize orders. This policy immediately impacts how burn garment claims are submitted and documented.
Action Required
Immediately effective as of January 15, 2026: (1) Billing Team: Update claim submission workflow to REJECT any burn garment claim (A6501-A6513) submitted without a completed Standard Written Order (SWO) from the treating practitioner. Implement system block to prevent billing until SWO is received and verified in medical record. (2) Prior Authorization/Documentation Team: Establish process to verify that all SWOs contain: member name/ID, order date, item description (HCPCS code/narrative/model), all concurrent options/accessories with separate HCPCS codes, quantity for each item, treating practitioner name and NPI, and treating practitioner signature. (3) Providers/Referring Physicians: Communicate that only MDs, DOs, PAs, NPs, and CNSs can authorize burn garments—physical therapists and occupational therapists cannot place orders. (4) Medical Records: Ensure medical record documentation includes evidence supporting all three medical necessity criteria: (a) documented significant burn placing member at risk of post-burn contracture, (b) garment/therapy intent to prevent skin grafting or hypertrophic scarring, (c) physician authorization. Supplier-prepared statements or attestations alone will NOT satisfy documentation requirements. (5) Claims Processing: Deny claims that lack corroborating medical record evidence beyond supplier statements. Consequence: All claims submitted without completed SWO or without sufficient medical record substantiation will be denied as not medically necessary per DME MAC policy.