Important Reminder: Effective August 1, 2018, Medical Policy and Coverage for Amniotic Membrane and Amniotic Fluid SUR704.011

September 14, 2018

Blue Cross and Blue Shield of Texas (BCBSTX) Medical Policy SUR704.011, Amniotic Membrane, and Amniotic Fluid became effective 8/1/2018.  Per the medical policy, the injection of micronized or particulated human amniotic membrane is considered experimental, investigational and/or unproven for all indications, including but not limited to treatment of osteoarthritis and plantar fasciitis.

Treatment of nonhealing diabetic lower-extremity ulcers using the following human amniotic membrane products (AmnioBand® Membrane, Biovance®, Epifix®, Grafix) may be considered medically necessary when there is medical record documentation of less than a 20% decrease in wound area with standard wound care for at least 2 weeks.

Sutured human amniotic membrane grafts may be considered medically necessary for the treatment of the following ophthalmic indications: Neurotrophic keratitis, Corneal ulcers and melts, Pterygium repair, Stevens-Johnson syndrome, and Persistent epithelial defects.

Please consult the medical policy for coverage criteria. If medical record documentation does not meet the requirement, claims will be denied. For additional information on the medical necessity requirements, refer to the link below:

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