HCPCS Level II › A codes A6220 Gauze >16 <=48 sq in w/bordrGauze, non-impregnated, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., with any size adhesive border, each dressing
Medicare coverage: Special coverage instructions apply Status: active (October 2026 file) Medically Unlikely Edits (effective October 1, 2026) Practitioner: max 0 units per day (clinical), rationale: CMS Policy Medicare pricing for A6220 DMEPOS fee schedule, July 2026 (DME26-C) no modifier, surgical dressings (SD): non-rural $3.69 in the contiguous states; $3.69 to $4.39 in AK, HI, PR and VI; ceiling $3.69, floor $3.14 Physician Fee Schedule (CY 2026, RVU26D) Status P: bundled or excluded, no separate PFS payment.
Payer policies and prior authorization for A6220 Payer coverage policies that name A6220 A6220 appears in 3 coverage policies from Aetna.
Payer Policy Role in policy Reviewed Document Aetna Dialysis (0541) covered if criteria are met (range A6010-A6457) Aug 26, 2026 payer document Aetna Surgical Devices, Dressings, and Wound Care Supplies (0526) covered if criteria are met (range A6216-A6221) Aug 26, 2026 payer document Aetna Urological Supplies (0533) not covered (range A6216-A6233) Jul 30, 2026 payer document
Medicaid fee-for-service Prior authorization required or conditional in CO, KY, LA, MA, OH, VA, WV.
AZ: $4.40 (dme), effective Oct 1, 2026 CO: $3.02 (chp_plus, non-facility), effective Jul 1, 2026 FL: $2.11 (dme), effective Jul 1, 2026 IL: $2.40 (dme), effective Jan 1, 2026 IN: $3.08 (professional, Advanced Practice Nurse (85%), non-facility), effective Jan 1, 2026 KS: $2.95 (default), effective Jul 1, 2026 KY: $2.46 (dme), effective Jan 1, 2026 LA: $1.66 (dme), effective Sep 1, 2021 MA: $3.01 (dme_rates), effective Mar 1, 2026 MD: $3.14 (dme), effective Apr 1, 2026 MS: $2.95 (comprehensive), effective Jul 1, 2026 ND: $4.55 (dme), effective Aug 1, 2026 NE: $3.22 (dme), effective Jul 1, 2026 NY: $1.09 (dme), effective Jul 1, 2026 OH: $2.58 (dme), effective Jun 28, 2006 OK: $3.69 (dme), effective Jan 1, 2026 TX: $2.46 (dmepos_tos_9_e_j_l_and_r, Home Health Dme, non-facility), effective Jul 1, 1997 VA: $3.32 (dme), effective Dec 1, 2026 VT: $0.00 (outpatient_hospital_opps), effective Feb 1, 2026 WA: $2.77 (medical_equipment_supplies), effective Jul 1, 2026 WY: $0.00 (outpatient_hospital_apc, Children's Hospitals), effective Apr 1, 2026 From payers' published prior-auth lists, coverage policies and state Medicaid fee schedules, updated Oct 16, 2026. The role is what the policy's own code table or text says about the code. Not a guarantee of coverage or payment; verify with the payer. CPT® is a registered trademark of the American Medical Association.