C9353, Microporous collagen implantable slit tube (neurawrap nerve protector), per
HCPCS/CPT
Prior Authorization
Prior Auth Required
Code explicitly requires prior authorization (high confidence)
Documentation Required
- No specific documentation requirements, prior authorization criteria, or required clinical documentation are stated in this CPB. (Policy contains literature review, statements of experimental/investigational status, and lists of CPT/HCPCS/ICD-10 codes not covered, but does not specify required documentation fields.)
- Product-specific application details: documentation of product lot, size, number of applications, fixation method (sutures, staples, adhesives), and whether single or multiple applications were performed (many devices are single-use and dosage is per cm2 or per mg for particulates).
- For use of biologic implants/allografts/xenografts: documentation of patient allergies or sensitivities (e.g., known porcine sensitivity excludes Mediskin), informed consent noting product source (human, porcine, bovine, ovine), and rationale for selection.
Key Coverage Criteria
- Prompt repair of acute phrenic nerve transection due to trauma or surgery. (Note in policy: "Phrenic nerve reconstruction for the treatment of diaphragmatic paralysis (Note: this does not apply to prompt repair of acute phrenic nerve transection due to trauma or surgery)")
- No other specific indications are affirmatively listed as covered in this CPB; multiple nerve grafting and nerve reconstruction interventions are described in the literature review but are explicitly identified in this policy as experimental and investigational (see Limitations).
- Use of acellular human dermal allograft in rhinoplasty
- Healing septal perforations using acellular dermis as bioscaffold
- Artiss is approved for attachment of skin grafts onto burn patients (clinical trial basis described).
- AlloSkin: As an allogeneic human, cadaver-derived skin graft for the management of traumatic skin wounds and burn wounds if the wound is too large for autograft. (Note: not AlloSkin AC or AlloSkin RT, which are different products).
4 Active Policies
AETNA-CPB-0416, Nerve Grafting and Reconstruction: Selected Indications
AETNA-CPB-0244, Skin and Soft Tissue Substitutes
EVICORE-HPLAN-CIGNA-1815296EE67F, Cigna Comprehensive Code List - Effective 03/07/2026
EVICORE-HPLAN-CIGNA-57D571603CB4, Cigna Commercial Other Services Code List - Effective 03/07/2026
Related Codes
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