Q4106, Dermagraft, per square centimeter
HCPCS/CPT
Prior Authorization
Prior Auth Required
Conditional coverage; review criteria to confirm PA need (medium confidence)
Documentation Required
- For chronic wound indications: documentation of wound duration (e.g., >3, >4, or >6 weeks as required by the specific product) and that standard therapy has failed.
- Documentation of standard wound therapy provided and its failure (description of off-loading, wound cleansing/debridement, infection management, compression therapy for venous ulcers, etc.).
- For diabetic foot ulcers: documentation of diabetes type (type 1 or 2) and hemoglobin A1c (HbA1c) value demonstrating HbA1c < 12%.
- Documentation of adequate blood supply to the treated foot/limb: presence of a palpable pedal pulse or an ankle-brachial index (ABI) >= 0.70.
Key Coverage Criteria
- InnovaMatrix FD: management of pressure ulcers, diabetic ulcers, vascular ulcers, tunneled/undermined wounds, surgical wounds, trauma wounds and draining wounds.
- Wound coverage — autologous skin grafts (CPT 15040-15261) are considered medically necessary for wound coverage.
- Wound coverage — unprocessed allogeneic human (cadaver) skin grafts (CPT 15271-15278; HCPCS Q4100) are considered medically necessary for wound coverage.
- Wound coverage — unprocessed xenogeneic pig skin grafts (CPT 15271-15278; HCPCS Q4100) are considered medically necessary for wound coverage.
- Breast reconstruction — use of acellular dermal matrices/skin substitutes (e.g., AlloDerm Q4116; AlloMax; Cortiva; DermACELL; FlexHD; GalaFLEX scaffolds) is considered medically necessary when used in association with a covered, medically necessary breast reconstruction procedure.
- Burn wounds — Biobrane: considered medically necessary when used for temporary covering of a partial-thickness freshly debrided or excised burn wound.
7 Active Policies
AMBETTER-CP.MP.185, Skin and Soft Tissue Substitutes for Diabetic Foot Ulcers and Venous Leg Ulcers
CIGNA-0068, Tissue Engineered Skin Substitutes
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
Related Codes
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