Skin and Soft Tissue Substitutes (CPB 0244, reviewed 2026-07-29)

By 2026-07-29: Billing team must implement the following changes to comply with Aetna's updated skin and soft tissue substitute policy: (1) Update prior authorization requirements in billing system to mandate submission of wound photographs with ruler, wound characteristics documentation, and treatment history for all skin substitute products before claim submission; (2) Create/update encounter forms and clinical documentation templates to capture required fields including: patient age verification (must be ≥18 years), smoking status attestation with documentation of smoking cessation enrollment if applicable, baseline wound size/depth measurements, evidence of at least 4 weeks of failed standard wound care (debridement, standard dressings, compression, off-loading), circulation studies for DFU/VLU (ABI results, Doppler findings, or physical exam documentation), and product-specific criteria (Hgb A1c ≤8% for DFU, adequate circulation confirmation); (3) Ensure providers document elimination of underlying conditions preventing healing (arterial insufficiency, nutritional deficiencies, infection, osteomyelitis, foreign bodies); (4) For diabetic foot ulcers: require documentation of Hgb A1c results and circulation adequacy (ABI >0.7-1.2, palpable pulses, or Doppler confirmation) before billing; (5) For venous leg ulcers: require compression therapy documentation and ABI ≥0.7; (6) For burn wounds: require documentation that autografting was insufficient/infeasible, burn wound is excised with necrotic tissue removed, and homeostasis achieved; (7) Train billing staff to deny or request additional information for claims missing required documentation, as Aetna explicitly reserves the right to require additional records for coverage determinations; (8) Update system to flag claims for specific products (Alloderm-RTU, Apligraf, Dermagraft, DermACELL, AmnioBand, AlloPatch, Biobrane, Artiss) and route to clinical review team to verify product-specific indications are met before processing; (9) Communicate to providers that off-label or experimental uses of these products (outside stated indications) will be denied; (10) Implement system alerts to require wound size documentation of at least 1 cm² for all chronic wound claims and ensure clean, debris-free wound status is documented. Claims submitted without complete documentation will be denied or returned for additional information.