Subject:
Unna Boot
Description:
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IMPORTANT NOTE:
The purpose of this policy is to provide general information applicable to the administration of health benefits that Horizon Blue Cross Blue Shield of New Jersey and Horizon Healthcare of New Jersey, Inc. (collectively “Horizon BCBSNJ”) insures or administers. If the member’s contract benefits differ from the medical policy, the contract prevails. Although a service, supply or procedure may be medically necessary, it may be subject to limitations and/or exclusions under a member’s benefit plan. If a service, supply or procedure is not covered and the member proceeds to obtain the service, supply or procedure, the member may be responsible for the cost. Decisions regarding treatment and treatment plans are the responsibility of the physician. This policy is not intended to direct the course of clinical care a physician provides to a member, and it does not replace a physician’s independent professional clinical judgment or duty to exercise special knowledge and skill in the treatment of Horizon BCBSNJ members. Horizon BCBSNJ is not responsible for, does not provide, and does not hold itself out as a provider of medical care. The physician remains responsible for the quality and type of health care services provided to a Horizon BCBSNJ member.
Horizon BCBSNJ medical policies do not constitute medical advice, authorization, certification, approval, explanation of benefits, offer of coverage, contract or guarantee of payment.
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Unna boot is a medicated dressing impregnated with zinc oxide, calamine and gelatin applied from the base of the toes to just below the knee.
Policy:
(NOTE: For Medicare Advantage, Medicaid and FIDE-SNP, please refer to the Coverage Sections below for coverage guidance.)
Unna boot is medically necessary for venous stasis ulcerations of the lower extremity and for lower extremity burns as an adjunct to excision and grafting.
Medicare Coverage:
There is no National Coverage Determination (NCD). In the absence of an NCD, coverage decisions are left to the discretion of Local Medicare Carriers. Novitas Solutions, Inc, the Local Medicare Carrier for jurisdiction JL, has determined that when both a debridement is done and an Unna boot is applied, only the debridement will be reimbursed. If only an Unna boot is applied and the wound is not debrided, then the Unna boot application is eligible for reimbursement. For additional information and eligibility, refer to Local Coverage Determination (LCD): Wound Care (L35139). Available to be accessed at CMS National Coverage Determinations (LCDs) Alphabetical Index search page: https://www.cms.gov/medicare-coverage-database/indexes/lcd-alphabetical-index.aspx?DocType=All
Medicaid Coverage:
For members enrolled in Medicaid and NJ FamilyCare plans, Horizon BCBSNJ applies the above medical policy.
FIDE SNP:
For members enrolled in a Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP): (1) to the extent the service is covered under the Medicare portion of the member’s benefit package, the above Medicare Coverage statement applies; and (2) to the extent the service is not covered under the Medicare portion of the member’s benefit package, the above Medicaid Coverage statement applies.
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Horizon BCBSNJ Medical Policy Development Process:
This Horizon BCBSNJ Medical Policy (the “Medical Policy”) has been developed by Horizon BCBSNJ’s Medical Policy Committee (the “Committee”) consistent with generally accepted standards of medical practice, and reflects Horizon BCBSNJ’s view of the subject health care services, supplies or procedures, and in what circumstances they are deemed to be medically necessary or experimental/ investigational in nature. This Medical Policy also considers whether and to what degree the subject health care services, supplies or procedures are clinically appropriate, in terms of type, frequency, extent, site and duration and if they are considered effective for the illnesses, injuries or diseases discussed. Where relevant, this Medical Policy considers whether the subject health care services, supplies or procedures are being requested primarily for the convenience of the covered person or the health care provider. It may also consider whether the services, supplies or procedures are more costly than an alternative service or sequence of services, supplies or procedures that are at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the relevant illness, injury or disease. In reaching its conclusion regarding what it considers to be the generally accepted standards of medical practice, the Committee reviews and considers the following: all credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, physician and health care provider specialty society recommendations, the views of physicians and health care providers practicing in relevant clinical areas (including, but not limited to, the prevailing opinion within the appropriate specialty) and any other relevant factor as determined by applicable State and Federal laws and regulations.
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Index:
Unna Boot
References:
1. Rubin JR, Alexander J, Plecha EJ, et al. Unna’s Boot vs Polyurethane Foam Dressing for the Treatment of Venous Ulceration. Arch Surg. 1990 April;125:489-490.
2. Barone CM, Mastropieri CJ, Peebles R, et al. Evaluation of the Unna Boot for lower-extremity autograft burn wounds excoriated by pruritus in pediatric patients. J Burn Care Rehabil . 1993 May-Jun;14(3):348-349.
3. Cox GW, Griswold JA. Outpatient skin grafting of extremity burn wounds with the use of Unna Boot compression dressings. J Burn Care Rehabil . 1993 Jul-Aug;14(4):455-457.
4. Falanga V. Care of venous leg ulcers. Ostomy Wound Manage 1999 Jan;45(1A Suppl):33S-43S.
5. Margolis DJ, Berlin JA, Strom BL. Which venous leg ulcers will heal with limb compression bandages? Am J Med . 2000 Jul;109(1):15-19.
6. Cullum N, Nelson EA, Fletcher AW, et al. Compression for venous leg ulcers. Cochrane Database Syst Rev. 2001;(2):CD000265.
7. Polignano R, Bonadeo P et al. A randomized controlled study of four-layer compression versus Unna’s Boot for venous ulcers. J Wound Care. 2004 Jan;13(1):21-4.
8. Empire Medicare Services (NJ). Unna Boot. LCD # L19483, 09/06/05. Available at: http://www.empiremedicare.com/newjpolicy/policy/l19483_final.htm (accessed 10/3/05).
9. Landsdown AB, Mirastschijski U et al. Zinc in wound healing: theoretical, experimental, and clinical aspects. Wound Repair Regen. 2007 Jan-Feb;15(1):2-16.
10. Novitas Solutions. LCD L27547 - Wound Care. Revision effective date: 09/01/14. Available at: http://www.novitas-solutions.com/LCDSearchResults/faces/spaces/search/page/lcd.jspx?Jurisdiction=JL&_afrLoop=856846501449000&State=New+Jersey&_afrWindowMode=0&lcdID=L27547&medicareType=Part+B&_adf.ctrl-state=nac2am6d7_4 (accessed 12/01/14)
11. UpToDate. Compression therapy for the treatment of chronic venous insufficiency. Literature review current through: Oct 2015; This topic last updated: Oct 5, 2015.
12. Armstrong DG, Meyr AJ. Compression therapy for the treatment of chronic venous insufficiency. In: UpToDate, Mills Sr JL, Eidt JF, Collins KA (Eds), UpToDate, Waltham, MA. (Accessed on November 8, 2017.)
13. Alguire PC, Mathes BM. Medical management of lower extremity chronic venous disease. In: UpToDate, Eidt JF, Mills Sr JL, Collins KA. UpToDate, Waltham, MA. (Accessed on November 8, 2017.)
14. Tenenhaus M, Rennekampff H-O. Local treatment of burns: Topical antimicrobial agents and dressings. In: UpToDate, Jeschke MG, Collins KA (Eds), UpToDate, Waltham, MA. (Accessed on November 8, 2017.)
15. Armstrong DG, Meyr AJ. Compression therapy for the treatment of chronic venous insufficiency. In: UpToDate, Mills Sr JL, Eidt JF, Collins KA (Eds), UpToDate, Waltham, MA. (Accessed on October 9, 2018.)
16. Alguire PC, Mathes BM. Medical management of lower extremity chronic venous disease. In: UpToDate, Eidt JF, Mills Sr JL, Collins KA. UpToDate, Waltham, MA. (Accessed on October 9, 2018.)
17. Wiechman S. Management of burn wound pain and itching. In: UpToDate, Jeschke MG, Collins KA.(Eds). UpToDate, Waltham, MA. (Accessed on October 9, 2018.)
18. Armstrong DG, Meyr AJ. Compression therapy for the treatment of chronic venous insufficiency. In: UpToDate, Mills Sr JL, Eidt JF, Collins KA (Eds), UpToDate, Waltham, MA. (Accessed on October 7, 2019.)
19. Alguire PC, Mathes BM. Medical management of lower extremity chronic venous disease. In: UpToDate, Eidt JF, Mills Sr JL, Collins KA. UpToDate, Waltham, MA. (Accessed on October 7, 2019.)
20. Wiechman S, Sharar SR. Management of burn wound pain and itching. In: UpToDate, Jeschke MG, Collins KA.(Eds). UpToDate, Waltham, MA. (Accessed on October 7, 2019.)
Codes:
(The list of codes is not intended to be all-inclusive and is included below for informational purposes only. Inclusion or exclusion of a procedure, diagnosis, drug or device code(s) does not constitute or imply authorization, certification, approval, offer of coverage or guarantee of payment.)
CPT*
HCPCS
* CPT only copyright 2019 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
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Medical policies can be highly technical and are designed for use by the Horizon BCBSNJ professional staff in making coverage determinations. Members referring to this policy should discuss it with their treating physician, and should refer to their specific benefit plan for the terms, conditions, limitations and exclusions of their coverage.
The Horizon BCBSNJ Medical Policy Manual is proprietary. It is to be used only as authorized by Horizon BCBSNJ and its affiliates. The contents of this Medical Policy are not to be copied, reproduced or circulated to other parties without the express written consent of Horizon BCBSNJ. The contents of this Medical Policy may be updated or changed without notice, unless otherwise required by law and/or regulation. However, benefit determinations are made in the context of medical policies existing at the time of the decision and are not subject to later revision as the result of a change in medical policy
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