Prior Authorization Review Panel MCO Policy Submission A separate copy of this form must accompany each policy submitted for review. Policies submitted without this form will not be considered for review. Plan: Aetna Better Health Submission Date:09/01/2019 Policy Number: 0244 Effective Date: Revision Date: 07/25/2019 Policy Name: Wound Care Type of Submission – Check all that apply: New Policy Revised Policy* Annual Review – No Revisions Statewide PDL *All revisions to the policy must be highlighted using track changes throughout the document. Please provide any clarifying information for the policy below: CPB 0244 Wound Care This CPB is revised to state that the following are considered medically necessary: 1) Epifix for the treatment of difficult-to-heal chronic venous partial and full-thickness ulcers of the lower extremity that have failed standard wound therapy of at least 4-weeks duration; 2) DermACELL for the treatment of partial and full‐thickness neuropathic diabetic foot ulcers that are greater than 6 weeks in duration with no capsule, tendon or bone exposed, when used in conjunction with standard diabetic ulcer care. This CPB has been revised to state that the following are considered experimental and investigational: ACM Surgical Collagen, ACM Surgical Extra Advanced Collagen, ACM Surgical Extra Advanced Collagen Powder, Allogen, AlloGen Liquid, AlloPatch Pliable, AlphaGems, AltiPlast, AltiPly, Ambio Choice, AmnioArmor, AmnioBand Allograft Placental Matrix, AmnioCord, AmnioFill, Amnion Bio, Amnios, AmnioWrap2, AmnyoFluid, Aquacel Ag, Artacent Cord, Arthrex Amnion Matrix, Arthrex Amnion Viscous, Ascent, AxoBioMembrane, Axolotl Ambient, Axolotl Cryo, Axolotl DualGraft, Axolotl Graft, BellaCell HD, BioFix Flow Placental Tissue Matrix Allograft, BioSkin Flow, BioWound Membrane, BioWound Plus Membrane, BioWound XPlus Membrane, Cellesta Cord, Cellesta Duo, Cellesta Flowable Amnion, Colla-Pad, CollaSorb, CollaWound, Coll-e-Derm, Collexa, Derma-Gide, Fluid Flow, Fluid GF, Genesis Amniotic Membrane, Grafix cryo-preserved placental membrane, GraftJacket RTM, Helicoll, InteguPly, Kerasorb Wound Matrix, Keroxx Flowable Wound Matrix, Matrion, Membrane Graft, Membrane Wrap, Merigen, MicroMatrix, MyOwn Skin, Novachor, Novafix, Ologen, Omega3 Wound, Plurivest, ProgenaMatrix, Puracol Plus, Renuva, Restorigin Amnion Patch, Restorigin Amniotic Fluid Therapy, Restrata, SkinTE, Stravix PL, SureDerm, SurgiCORD, surgiGRAFT, surgiGRAFT-DUAL, SurGraft, TheraForm, VersaWrap Tendon Protector, WoundEx Membrane, WoundFix Membrane, WoundFix Plus Membrane, WoundFix XPlus Membrane, and Xwrap Amniotic Membrane Derived Allograft.
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