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Hyalomatrix®

Anika Therapeutics

HYALOMATRIX is a bi-layered, sterile and flexible advanced wound care device. It is ideally suited for a range of wounds that include pressure ulcers, diabetic foot ulcers and deep second-degree burns.

Hyalomatrix is a non-woven pad comprised of a wound contact layer made of a derivative of hyaluronic acid (HA) in fibrous form with an outer layer comprised of a semipermeable silicone membrane. The wound contact layer is biodegradable, and it acts as a 3D scaffold for cellular invasion and capillary growth. The silicone layer controls water vapor loss and provides protective coverage of the wound.

Hyalomatrix  is not derived from human or animal tissue. The HA is created in laboratory through recombinant DNA technology. The genetic code for HA is programmed into a bacterial cell, and the bacteria then produce HA in a controlled environment.

  • MSS4011: Hyalomatrix, 2.5 x 2.5 cm 10/bx* 6.25 cm2, 1 device per pouch
  • MSS4022: Hyalomatrix, 5 x 5 cm 10/bx* 25 cm2, 1 device per pouch
  • MSS4044: Hyalomatrix, 10 x 10 cm 1/bx 100 cm2
  • MSS4048: Hyalomatrix, 10 x 20 cm 1/bx 200 cm2
* The product information contained on this page, including the product images and additional product materials, was collected from various supplier sources. All product claims and specifications are those of the product suppliers. Every effort has been made to ensure the accuracy of the product information, however on occasion manufacturers may alter their products or packaging without notice. Wound Reference assumes no liability for inaccuracies or misstatements about products. The properties of a product may change or be inaccurate following the posting or printing of the product information in the document, either in the print or online version. Due to product changes, information listed in this document is subject to change without notice. We recommend that you always read labels, warnings and instructions for use before using a product. Content on this site is for reference purposes and is not intended to be a substitute for professional advice given by a physician or other licensed healthcare professional.

ESSENTIALS

Product
Rating
Suppliers Price
HCPCS Class
HCPCS
Hyalomatrix, per square centimeter
Hyalomatrix, per square centimeter
Q4117
* Hover on the information button next to each header for detailed explanation on the type of information provided by the table
Choose the state for Medicare
DME coverage and co-payment
Manufacturer
Product
Rating
Suppliers Price
Patient DME Co-Payment per Billable Unit
DME Reimbursement to Suppliers
Frequency Replacement if Requirements Met
Office and/or Facility - Product reimbursement
Hyalomatrix, per square centimeter
$.00
per square centimeter (non-DMEPOS)
See Coding, Coverage and Reimbursement
* Every effort has been made to ensure the accuracy of the product information, however you should visit the manufacturer's website for the latest information.
* Hover on the information button next to each header for detailed explanation on the type of information provided by the table
Product
Rating
Suppliers Price
Recom / Evidence
FDA Safety
Quality Measures
Cost Effectiveness
Product
Rating
Suppliers Price
Features
Hyalomatrix, per square centimeter
Configuration: Sheet May apply on full-thickness wounds Storage: room temp
CPT CodeDescription Physician Reimbursement - Office Physician Reimbursement - Facility Facility Reimbursement
C5271Application of low cost skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area
C5273Application of low cost skin substitute graft to trunk, arms, legs, total wound surface area greater than or equal to 100 sq cm; first 100 sq cm wound surface area, or 1% of body area of infants and children
C5274Application of low cost skin substitute graft to trunk, arms, legs, total wound surface area greater than or equal to 100 sq cm; each additional 100 sq cm wound surface area, or part thereof, or each additional 1% of body area of infants and children, or part thereof (list separately in addition to code for primary procedure)
C5275Application of low cost skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area
C5272Application of low cost skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; each additional 25 sq cm wound surface area, or part thereof (list separately in addition to code for primary procedure)
C5276Application of low cost skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area up to 100 sq cm; each additional 25 sq cm wound surface area, or part thereof (list separately in addition to code for primary procedure)
C5277Application of low cost skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area greater than or equal to 100 sq cm; first 100 sq cm wound surface area, or 1% of body area of infants and children
C5278Application of low cost skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area greater than or equal to 100 sq cm; each additional 100 sq cm wound surface area, or part thereof, or each additional 1% of body area of infants and children, or part thereof (list separately with primary procedure)
  • Based on national averages
  • Medicare payments for participating qualified health professionals (QHP) for services performed in their Offices (*) or at a Facility (** i.e., hospital outpatient department or ambulatory service center). Payments are nationally unadjusted average amounts, and do not account for differences in payment due to geographic variation. The allowed rate for non-participating physicians is set at 95% of the allowable for participating physicians. Non-participating physicians are subject to the limiting charge rules. The coinsurance is limited to 20% of the allowable fee.
  • When covered by the Medicare contractor, this manufacturer product is separately payable in a QHP office based on the Average Sales Price (ASP) as reported by the manufacturer on a quarterly basis.
  • Hover on the information button next to each header for detailed explanation on the type of information provided by the table
  • The information provided on this website is informational only. This is not a guarantee of Reimbursement Rates, nor is it intended to make recommendations regarding clinical practices. Information on this website is subject to change with out notice due to changes in reimbursement laws, regulations, rules and policies. The ultimate responsibility for correct coding lies with the provider of services. Please contact the appropriate payer for their interpretation of the appropriate code to use for the procedure.
  • CPT® is a registered trademark of the American Medical Association. All CPT codes and descriptions are copyrighted 2018, American Medical Association. All rights reserved. CPT codes and CPT descriptions are from the current manuals and those included herein are not intended to be all-inclusive and are included for informational purposes only. Codes referenced on Wound Reference are for informational purposes only. Inclusion or exclusion of any codes does not guarantee coverage. Providers should reference the American Medical Association prior to the submission of claims for reimbursement of covered services.

CLINICAL

Indications

Indicated for the management of wounds including: partial and full-thickness wounds; second-degree burns; pressure ulcers; venous ulcers; diabetic ulcers; chronic vascular ulcers; tunneled/undetermined wounds; surgical wounds (donor sites/grafts, post-Mohs surgery, post-laser surgery, podiatric, wound dehiscence); trauma wounds (abrasions, lacerations, skin tears); and draining wounds. The device is intended for one-time use.

FDA 

Hyalomatrix PA Wound Dressing (Anika Therapeutics, Inc., Bedford, MA, USA) was cleared for marketing under the 510(k) process in December 2007 (K073251). The company refers to Hyalomatrix PA by its trade name Hyalomatrix. In the 510(k) documents Hyalomatrix is described as a bilayered dressing composed of a nonwoven pad made of HYAFF 11 and a semipermeable silicone membrane. Hyalomatrix is included in FDA product code FRO (dressing, wound, drug). The predicate device was “Hyalomatrix KC (Laserskin) Wound Dressing

CODING, COVERAGE AND REIMBURSEMENT

This section currently focuses primarily on Medicare. It may be expanded in the future to include information on private insurers as well. 

Frequency of replacement allowed by Medicare:



Medicare Administrative Contractor (MAC)Frequency of replacement if requirements met
Novitas Solutions, Inc.10 units in 12 weeks
CGS Administrators, LLC10 units in 12 weeks
Palmetto10 units in 12 weeks
First Coast Service Options, Inc. (FCSO)

1 type of product per 12 weeks, fewest repeat applications and amount of product is expected

Noridian

Wisconsin Physicians Service Insurance Corporation (WPS)

National Government Services, Inc. (NGS)

Carrier discretion

More details on requirements, medical necessity and documentation in specific Medicare Local Coverage Determinations (if available). See section on Coding, Coverage and Reimbursement in topic "Cellular and/or Tissue Products". 





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