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Date Printed: June 25, 2017: 01:17 PM

Private Property of Blue Cross and Blue Shield of Florida.
This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

09-A9000-02

Original Effective Date: 02/15/11

Reviewed: 12/01/11

Revised: 05/11/14

Subject: Biafine® Topical Emulsion

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
Other References Updates  

DESCRIPTION:

Biafine® Topical Emulsion (distributed by Ortho-Neutrogena, a division of Ortho-McNeil Pharmaceutical, Inc.) is a water-based emulsion formulated for the dressing and management of specific types of wounds such as full thickness wounds, pressure sores, dermal ulcers, graft sites, and radiation burns or necrosis.

POSITION STATEMENT:

Biafine topical emulsion meets the definition of medical necessity when prescribed by the attending physician for at least ONE of the following indications:

Biafine topical emulsion does not meet the definition of medical necessity when applied for ANY of the following indications or situations:

The use of Biafine topical emulsion on skin rashes due to allergies is considered experiment or investigational as it has not been studied sufficiently and therefore is not recommended by the manufacturer.

WARNINGS

  • In radiation therapy, BIAFINE may be applied as directed by the treating physician. Do not apply 4 hours prior to a radiation session.
  • Do not apply BIAFINE to dermal grafts until after the graft has successfully taken.

BILLING/CODING INFORMATION:

There is no specific procedure code describing Biafine® topical emulsion. Therefore, it would most likely be reported using a non-specific medical supply code (example: A6250).

LOINC Codes:

The following information may be required documentation to support medical necessity: Physician’s history and physical notes, physician progress and treatment notes, and current and administered medications.

Documentation Table

LOINC Codes

LOINC
Time Frame
Modifier Code

LOINC Time Frame Modifier Codes Narrative

Physician history and physical

28626-0

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Attending physician visit note or treatment notes

18733-6

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Attending physician progress note

18741-9

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Clinical notes and chart section

28650-0

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Current, discharge, or administered medications

34483-8

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

REIMBURSEMENT INFORMATION:

Refer to section entitled POSITION STATEMENT.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage products:

No National Coverage Determination (NCD) and/or Local Coverage Determination (LCD) were found at the time of the last guideline reviewed date.

DEFINITIONS:

No guideline specific definitions apply.

RELATED GUIDELINES:

None applicable.

OTHER:

None applicable.

REFERENCES:

  1. Heller M. Biafine for wound healing. Journal of Drugs for Dermatology, 2007 March.
  2. Kircik LH. Study of trolamine-containing topical emulsion for wound healing after shave biopsy. Cutis. 2009 Jun;83(6):326-32.
  3. Ortho Dermatologics Inc., Biafine Product Information. Accessed 01/27/11.
  4. Salvo N, Barnes E, van Draanen J, et al. Prophylaxis and management of acute radiation-induced skin reactions: a systematic review of the literature. Curr Oncol. 2010 Aug;17(4):94-112.
  5. Sarnoff DS. A comparison of wound healing between a skin protectant ointment and a medical device topical emulsion after laser resurfacing of the perioral area. J Am Acad Dermatol. 2011 Mar;64(3 Suppl):S36-43. Epub 2011 Jan 17.
  6. Trookman NS, Rizer RL, Weber T. Irritation and allergy patch test analysis of topical treatments commonly used in wound care: evaluation on normal and compromised skin. J Am Acad Dermatol. 2011 Mar;64(3 Suppl):S16-22. Epub 2011 Jan 17.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 01/27/11.

GUIDELINE UPDATE INFORMATION:

02/15/11

New Medical Coverage Guideline.

08/15/11

Revision; formatting changes.

12/15/11

Scheduled review; position statement unchanged; references updated.

05/11/14

Revision: Program Exceptions section updated.

Date Printed: June 25, 2017: 01:17 PM