As of December 24, 2025, CMS has withdrawn (not delayed) the Local Coverage Determinations (LCDs) for skin substitute grafts that were scheduled to take effect on January 1, 2026. Because these unified policies have been eliminated, there is currently no revised version of that specific LCD scheduled for 2026.
Instead, the following framework applies for 2026:
1. Reversion to "Legacy" Policies: Coverage rules revert to the existing individual Medicare Administrative Contractor (MAC) policies.
2. Novitas, First Coast, and CGS: These MACs will keep their current active coverage policies in place with no changes; their previously planned December 31, 2025 retirement dates have been removed.
3. Palmetto, NGS, WPS, and Noridian: These MACs continue to have no published LCD for skin substitutes. In these jurisdictions, coverage is determined on a case-by-case basis of whether the service is "reasonable and necessary".
4. Payment Rates Still Changing: While the coverage rules (LCDs) were withdrawn, the new payment rates finalized in the CY 2026 Physician Fee Schedule remain in effect. Starting January 1, 2026, most skin substitutes will be paid at a flat national rate of $127.14 per square centimeter.
5. Future Revisions: MACs are scheduled to reconsider the withdrawn evidence-based coverage standards and potentially release a revised, unified LCD in early 2027.
Providers in jurisdictions with active LCDs (Novitas, First Coast, CGS) should continue to follow their current requirements, while those in other regions must maintain rigorous documentation to justify medical necessity.
These updates explain how Medicare Part B MACs will determine coverage for skin substitutes after the elimination of the January 1, 2026 LCDs.
Without a New LCD That Was Supposed to Be in Effect on January 1, 2026, What Are The “Reasonable and Necessary” Standards That Palmetto, NGS, WPS and Noridian Will Use to Determine Coverage for the Application of Skin Substitutes in 2026?
Even though the new, unified LCDs were withdrawn, Palmetto, NGS, WPS, and Noridian will still use the core “reasonable and necessary” standards from Section 1862(a)(1)(A) of the Social Security Act, focusing on documented failure (greater than or equal to 4 weeks) of standard care (compression/offloading) for diabetic foot ulcers (DFUs) and venous leg ulcers (VLUs), comprehensive wound/vascular assessments, proper sizing/minimal wastage, continuous care, and evidence of clinical benefit, with individual MACs applying existing regional policies and the new $127.14/square centimeter rate for non-biologicals.
Key “Reasonable & “Necessary” Standards (Applied by MACs):
1. Failure of Standard Care: Documented non-response (no significant improvement) for at least 4 weeks of Standard of Care (SOC before skin substitute application.
2. Standard of Care (SOC) Compliance:
3. VLUs: Continuous, effective compression (greater than or equal to 20mmHg) or multilayer dressings.
4. DFUs: Appropriate offloading/footwear, glucose/nutrition control, vascular
assessment.
5. Comprehensive Wound/Patient Assessment: Detailed history, wound measurements (initial, weekly, pre-application), vascular status, and comorbidities.
6. Evidence-Based Application: Use of products with demonstrated clinical effectiveness and proper sizing (avoid excessive wastage).
7. Documentation: Meticulous records of all treatments, measurements, progress, and justification for each application.
8. Continuous Care: Documentation of ongoing care (weekly measurements, continued SOC) throughout the treatment course.
What This Means for Your Jurisdiction (as of Late 2025/Early 2026):
MAC-Specific Policies: Each Medicare Administrative Contractor (MAC) like Palmetto GBA, NGS, WPS, and Noridian, will continue to enforce its current LCDs where they exist, as the unified national ones were pulled.
Payment Rate: A new, standardized payment rate (around $127.14/sq cm) for most skin substitutes applies nationwide, affecting reimbursement regardless of the specific LCD.
Varied Requirements: Documentation demands and approved products will differ by MAC jurisdiction, requiring providers to check their specific MAC’s existing policies.
In essence, providers must rely on specific, accurate documentation proving the skin substitute is medically necessary after standard treatments fail, aligning with the specific rules of their MAC and new payment rules.
Michael G. Warshaw, DPM, CPC
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