C5274, Application of low cost skin substitute graft to trunk, arms, legs, total wound
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Procedure codes on Medical Policy documents are included only as a general reference tool and may not be all-inclusive.
- The presence or absence of procedure/service/supply/device codes in the policy does not determine benefit coverage or reimbursement; only the written coverage position should be used for determinations.
- Benefit coverage determinations must include review of the member's benefit contract or Summary Plan Description (SPD) for coverage definitions, exclusions, and limitations (e.g., dollar or duration caps).
- Policy Guidelines: None.
Key Coverage Criteria
- The following products are consideredmedically necessaryfor the treatment of diabetic foot ulcers when the clinical criteria below have been met:
- The following products are consideredmedically necessarywhen used for breast reconstruction surgery:
- AlloDerm Regenerative Tissue Matrix (aseptic or sterile);or
- Cortiva®;or
- DermACELLâ¢;or
- DermaMatrix®;or
5 Active Policies
ANTHEM-CG-SURG-127, CG-SURG-127 Products for Wound Healing and Soft Tissue Grafting: Medically Necessary Uses
BCBSIL-SUR704.012, Bioengineered Skin and Soft Tissue Substitutes
BCBSMT-SUR704.012, Bioengineered Skin and Soft Tissue Substitutes
BCBSNM-SUR704.012, Bioengineered Skin and Soft Tissue Substitutes
BCBSOK-SUR704.012, Bioengineered Skin and Soft Tissue Substitutes
Related Codes
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