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24.5.14.6 Wound Care System Criteria
Initial Criteria
Initial prior authorization for a wound care system may be considered for reimbursement for up to a 30-day period.
Recertification Criteria
Medically necessary prior authorized extensions may be considered for reimbursement for 30-day periods up to a maximum of four months when documentation supports continued significant improvement in wound healing. Wound care systems may be considered for reimbursement beyond four months of treatment on a case-by-case basis after review by the medical director or designee with documentation of medical necessity.
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