Independence Blue Cross

Lower Extremity Ulcers

Policy No.

11.08.20r

States
D.C.
Florida
Louisiana
New Hampshire
New Jersey
Pennsylvania
South Carolina
Grafix Core Q4132

Covered – DFU/VLU/DLEU/Burns/Deeptunneling Wounds/Pressure Ulcers/Pyoderma Gangrenosum/Surgical Dehiscence/Surgical Incisions

Grafix PL/Prime Q4133

Covered – DFU/VLU/DLEU/Burns/Deeptunneling Wounds/Pressure Ulcers/Pyoderma Gangrenosum/Surgical Dehiscence/Surgical Incisions