Mountain State Medical Policy Bulletin
Section: Surgery
Number: S-198
Topic: Acellular Dermal Grafts for Reconstruction
Effective Date: August 23, 2010
Issued Date: August 23, 2010
Date Last Reviewed: 10/2009

General Policy Guidelines

Indications and Limitations of Coverage

Acellular dermal grafts are considered human tissue for transplantation.  Acellular dermal material is considered a prosthetic device.

Guidelines are provided based on the specific products.

AlloDerm
AlloDerm (LifeCell Corporation) is considered medically necessary when used in conjunction with breast reconstruction following mastectomy, procedure codes 19357 – 19369. 

The use of AlloDerm for any other condition, including hernia repair, is considered experimental/investigational.  There is insufficient evidence in medical literature to support the effectiveness of these tissues.  A participating, preferred, or network provider can bill the member for the denied service.

When reported with breast reconstruction, incorporation of the AlloDerm tissue graft should be reported with code 19499.

When AlloDerm is supplied by the physician, it should be reported with code Q4116. Coverage for prosthetics is determined according to individual or group customer benefits

Description

Acellular dermal grafts are allogeneic tissues, derived from human cadavers and engineered to be acellular and immunologically inert. The tissue is enzymatically processed to remove the immunologically active cells, leaving behind an acellular collagen framework.  The matrix allows for fibroblast infiltration, collagen deposition, and neoepithelization. The graft is tolerated and not rejected because the immunologically active cells have been removed.

These grafts are used in a wide variety of conditions.  Some examples include urogynecologic procedures, including pelvic reconstruction, hernia repair, breast reconstruction, nipple reconstruction, full-thickness burns, nasal deformities, and lip augmentation.

Procedure Codes

193571936119364193661936719368
1936919499Q4116   

Traditional Guidelines

Refer to General Policy Guidelines

FEP Guidelines

This medical policy may not apply to FEP.  Medical policy is not an authorization, certification, explanation of benefits or a contract.  Benefits are determined by the Federal Employee Program.

PPO Guidelines

Refer to General Policy Guidelines

Managed Care POS Guidelines

Refer to General Policy Guidelines

Publications

References

Garramone C, Lam B. Use of AlloDerm in Primary Nipple Reconstruction to Improve Long-Term Nipple Projection. Plast Reconstruc Surg. May 2007;119(6): 1663-1668

Zienowicz R, Karacoaglu E. Implant-Based Breast Reconstruction with Allograft.  Plast Reconstru Surg. August 2007; 120(2): 373-81

Brueing K, Colwell A. Inferolateral AlloDerm Hammock for Implant Coverage in Breast Reconstruction.  Annals of Plastic Surgery.  September 2007;59(3): 250-55

Warren A, Morris D, houlihan M, Slavin S. Breast Reconstruction in a Changing Breast Cancer Treatment Paradigm. Plast Reconstruc Surg. April 2008:  1116 – 1126  www.plasticsurgery.org.  accessed September 16, 2009

Jin J, Rosen M, Blatnik J. et.al. Use of Acellular Dermal Matrix for Complicated Ventral Hernia Repair: Does Technique Affect Outcomes: J. Am Coll. Surg. November 2007;205(5). www.mdconsult.com.  Accessed August 28, 2009

Blubone-Langner R, Keifa E, Mithani S, et.al. Recurrent Adominal Laxity Following Interpositional Human Acellular Dermal Matrix.  Annals of Plastic Surgery. January 2008;60(1):76-80

Bachman S, Ramshaw B. Prosthetic Material in Ventral Hernia Repair: How Do I Choose? Surg Clin N Am.  February 2008;88(1): 101-112

Spear S, Parikh P, Reisin E, Menon N. Acellular Dermis-assisted Breast Reconstruction.  Aesth Plast Surg. March 13, 2008;32: 418-425

Preminger B, McCarthy C, Hu Q, Mehrara B, Disa J. The Influence of AlloDerm on Expander Dynamics and Complications in the Setting of Immediate Tissue Expander/Implant Reconstruction.  Annals of Plastic Surgery. May 2008;60(5): 510-513

Mofid M, Singh N. Pocket Conversion Made Easy: A Simple Technique Using AlloDerm to Convert Subglandular Breast Implants to the Dual-Plane Position.  Aesthetic Surgery Journal. January/February 2009;29: 12-18

Brueing K, Colwell A. Immediate Breast Tissue Expander-Implant Reconstruction with Inferolateral AlloDerm Hammock and Postoperative Radiation: A Preliminary Report. Journal of Plastic Surgery. May 15, 2009.  Accessed August 31, 2009 at www.eplasty.com

Hsinchen J, Spoerke N, Deveney C, Martindale R. Reconstruction of complex abdominal wall hernias using acellular human dermal matrix: a single institution experience. Am J Surg. May 2009; 197(5) Accessed August 28, 2009 at www.mdconsult.com

Becker S, Saint-Cyr M, Wong C, et. al. AlloDerm versus DermaMatrix in Immediate Expander-Based Breast Reconstruction: A Preliminary Comparison of Complication Profiles and Material Compliance. Plast Reconstr Surg. January 2009;123(1): 1-6

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This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern.

Medical policies do not constitute medical advice, nor the practice of medicine. Rather, such policies are intended only to establish general guidelines for coverage and reimbursement under Mountain State Blue Cross Blue Shield plans. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions.

Mountain State Blue Cross Blue Shield (MSBCBS) retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of MSBCBS. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.