Does A6261 require prior authorization?

Yes, A6261 requires prior authorization (high confidence). Code explicitly requires prior authorization.

What is the Medicare reimbursement rate for A6261?

Medicare facility rate: N/A. Non-facility rate: N/A. Work RVU: 0.00.

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`A6261`, Wound filler, gel/paste, per fluid ounce, not otherwise specified

HCPCS/CPT

Prior Authorization

Prior Auth Required

Code explicitly requires prior authorization (high confidence)

Medicare Pricing

Work RVU

0.00

Facility

N/A

Non-Facility

N/A

Documentation Required

A Standard Written Order (SWO) must be communicated to the supplier before a claim is submitted; for DMEPOS base items requiring Written Order Prior to Delivery (WOPD) the supplier must have the signed SWO before delivery.

Proof of delivery (POD) documentation must be maintained by the supplier and made available to the Medicare contractor upon request; lack of POD will result in denial.

Suppliers must document beneficiary contact and an affirmative refill request prior to dispensing refills; contact must occur no sooner than 30 calendar days before expected end of supply and delivery no sooner than 10 calendar days before expected end of supply.

Suppliers must monitor and document actual beneficiary utilization and verify with the treating practitioner any changed or atypical utilization patterns before dispensing additional supplies.

For DMEPOS base items that require a WOPD and have separately billed associated options/accessories/supplies, the WOPD must list the base item and may list the separately billed items prior to delivery.

Key Coverage Criteria

Medicare covers surgical dressings that are reasonable and necessary for diagnosis or treatment of illness or injury, for improving function of a malformed body member, and that meet all other Medicare statutory and regulatory requirements.
Alginate or other fiber gelling dressings (HCPCS A6196-A6199) are covered for moderately to highly exudative full thickness wounds (e.g., stage 3 or 4 ulcers) and for wound cavities, but are not covered for dry wounds or wounds covered with eschar.
Collagen-based dressings or wound fillers (HCPCS A6010, A6011, A6021-A6024) are covered for full thickness wounds (e.g., stage 3 or 4 ulcers), wounds with light to moderate exudate, or stalled wounds not progressing toward healing.
Composite dressings (HCPCS A6203-A6205) are covered for moderately to highly exudative wounds.
Contact layer dressings (HCPCS A6206-A6208) are covered to line the entire wound to prevent adhesion of overlying dressings when the overlying dressing lacks a non-adherent or semi-adherent layer.
Foam dressings (HCPCS A6209-A6215) are covered for full thickness wounds with moderate to heavy exudate and as secondary dressings for wounds with very heavy exudate.

3 Active Policies

EVICORE-HPLAN-CIGNA_MEDICARE-268F28B96146, Cigna Medicare Advantage Durable Medical Equipment Code List - Effective 01/01/2025

L33831, Surgical Dressings

AETNA-CPB-0526, Surgical Devices, Dressings, and Wound Care Supplies

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A6261, Wound filler, gel/paste, per fluid ounce, not otherwise specified