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24.5.14.1 Wound Care Supplies
Nonsterile/clean wound care supplies may be considered for prior authorization when documentation supports medical necessity. The home setting is considered a clean environment, not a sterile environment.
Sterile wound care supplies, other than those required with a wound care system, may be considered for prior authorization when documentation supports medical necessity and justifies that nonsterile/clean wound care supplies will not meet the client's needs.
Note: Established tracheostomies and/or gastrostomies/buttons are not considered wounds, therefore dressing supplies will not be considered for prior authorization. Dressing supplies for tracheostomies and/or gastrostomies may be considered for prior authorization with documentation of medical necessity.
To request prior authorization for wound care supplies, the following documentation must be provided:
• Accurate diagnostic information pertaining to the underlying diagnosis/condition as well as any other medical diagnoses/conditions, to include the client's overall health status.
•Appropriate medical history related to the current wound:
•Wound measurements to include length, width and depth, any tunneling and/or undermining.
•Wound color, drainage (type and amount) and odor, if present.
•The prescribed wound care regimen, to include frequency, duration and supplies needed.
•Treatment for infection, if present.
•The client's use of a pressure reducing mattress and/or cushion, when appropriate.
•Identification of the client or caregiver who will be instructed how to perform and will be responsible for the wound care.
Note: Nonsterile gloves may be considered for prior authorization when necessary to perform medical wound care provided by the client, a family member, or a friend. The home health nursing agency must provide their staff with the appropriate safety supplies as stated in the Occupational Safety and Health Administration (OSHA) requirements. Non-sterile/sterile gloves for use by a health-care provider in the home setting, such as an RN, LVN, or attendant are not a benefit.
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