G0684, Application of a premarket approval (pma), 510(k), 361 human cells, tissues or
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
- Medically necessary use of allogeneic acellular dermal matrix products for breast reconstruction when there is insufficient tissue expander/implant coverage, or compromised/thin postmastectomy skin flaps at risk of dehiscence/necrosis, or undermined inframammary/lateral folds needing reestablishment.
- Medically necessary: Breast reconstructive surgery using allogeneic acellular dermal matrix products (AlloDerm, Cortiva, DermACELL, DermaMatrix, FlexHD, FlexHD Pliable) when there is insufficient tissue expander/implant coverage, or compromised/thin postmastectomy skin flaps at risk of dehiscence/necrosis, or undermined inframammary/lateral folds requiring landmark reestablishment.
- Medically necessary use of allogeneic acellular dermal matrix (ADM) products for breast reconstruction when there is insufficient coverage by tissue expander/implant, or compromised/thin skin flaps at risk of dehiscence/necrosis, or undermined inframammary/lateral folds needing landmark reestablishment.
- Porcine (pig) skin dressings are covered by CMS as occlusive dressings for burns, donor sites of a homograft, and decubiti and other ulcers when reasonable and necessary for the individual patient.
4 Active Policies
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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