HCPCS Level II › A codes A6222 Gauze <=16 in no w/sal w/o bGauze, impregnated with other than water, normal saline, or hydrogel, sterile, pad size 16 sq. in. or less, without 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 A6222 DMEPOS fee schedule, July 2026 (DME26-C) no modifier, surgical dressings (SD): non-rural $3.04 in the contiguous states; $3.04 to $3.66 in AK, HI, PR and VI; ceiling $3.04, floor $2.58 Physician Fee Schedule (CY 2026, RVU26D) Status P: bundled or excluded, no separate PFS payment.
Payer policies and prior authorization for A6222 Payer coverage policies that name A6222 A6222 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 A6222-A6233) 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: $3.63 (dme), effective Oct 1, 2026 CO: $2.08 (chp_plus, non-facility), effective Jul 1, 2026 FL: $1.75 (dme), effective Jul 1, 2026 IL: $2.08 (dme), effective Jan 1, 2026 IN: $2.53 (professional, Advanced Practice Nurse (85%), non-facility), effective Jan 1, 2026 KS: $2.43 (default), effective Jul 1, 2026 KY: $2.03 (dme), effective Jan 1, 2026 LA: $1.37 (dme), effective Sep 1, 2021 MA: $2.47 (dme_rates), effective Mar 1, 2026 MD: $2.58 (dme), effective Apr 1, 2026 MS: $2.43 (comprehensive), effective Jul 1, 2026 ND: $0.00 (dme), effective Aug 1, 2026 NE: $2.65 (dme), effective Jul 1, 2026 NY: $1.45 (dme), effective Jul 1, 2026 OH: $1.82 (dme), effective Jan 1, 2024 OK: $3.04 (dme), effective Jan 1, 2026 TX: $2.03 (dmepos_tos_9_e_j_l_and_r, Home Health Dme, non-facility), effective Jul 1, 1997 VA: $2.74 (dme), effective Dec 1, 2026 VT: $0.00 (outpatient_hospital_opps), effective Feb 1, 2026 WA: $2.28 (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.