Does Q4116 require prior authorization?

Yes, Q4116 requires prior authorization (medium confidence). Conditional coverage; review criteria to confirm PA need.

What is the Medicare reimbursement rate for Q4116?

Medicare facility rate: $127.26. Non-facility rate: $127.26. Work RVU: 0.00.

Verity

`Q4116` — Alloderm, per square centimeter (add-on, list separately in addition to primary procedure)

HCPCS/CPT

Prior Authorization

Prior Auth Required

Conditional coverage; review criteria to confirm PA need (medium confidence)

Medicare Pricing

Work RVU

0.00

Facility

$127.26

Non-Facility

$127.26

Documentation Required

ChronOS / TCP with bone marrow studies: documentation of diagnosis (benign cystic bone lesion type: non-ossifying fibroma, enchondroma, fibrous dysplasia, aneurysmal bone cyst, juvenile bone cyst), operative records showing mixing of ChronOS granules with autologous bone marrow harvested during surgery, and radiographic follow-up using Neer classification for bone regeneration.
For antibiotic bead local therapy (calcium sulfate beads): operative notes documenting debridement and bead placement, systemic antibiotic regimen, culture results, and follow-up documentation of wound status (presence/character of wound discharge) and radiographic dissolution of beads (authors reported beads dissolved at average ~36 days).
For INFUSE lumbar fusion: documentation that 'The member meets medical necessity criteria for lumbar spinal fusion in CPB 0743 - Spinal Surgery: Laminectomy and Fusion' and that 'INFUSE Bone Graft is to be implanted via an anterior (ALIF) or lateral (OLIF, DLIF, XLIF or LLIF) approach.'

Key Coverage Criteria

posterolateral lumbar fusion
cervical interbody fusion
fracture healing / nonunion fractures
long bone nonunion (tibial nonunions referenced)
treatment of open tibial fractures
healing nonunion fractures

19 Active Policies

A59739 — Billing and Coding: Skin Substitutes Grafts/Cellular Tissue-Based Products for the Treatment of Diabetic Foot Ulcers and Venous Leg Ulcers

J05

A59740 — Billing and Coding: Skin Substitutes Grafts/Cellular Tissue-Based Products for the Treatment of Diabetic Foot Ulcers and Venous Leg Ulcers

J05

A59711 — Billing and Coding: Skin Substitutes Grafts/Cellular Tissue-Based Products for the Treatment of Diabetic Foot Ulcers and Venous Leg Ulcers

J06

A59712 — Billing and Coding: Skin Substitutes Grafts/Cellular and Tissue-Based Products for the Treatment of Diabetic Foot Ulcers and Venous Leg Ulcers

J06

Have a follow-up question?

Ask Verity about documentation requirements, denial risks, or coverage in your state.

For INFUSE in tibial shaft fractures: documentation that the patient is skeletally mature; that the acute, open tibial shaft fracture has been stabilized with intramedullary nail fixation; that appropriate wound management was performed; and that INFUSE Bone Graft will be applied within 14 days after the initial fracture.

For PMMA or calcium sulfate antibiotic beads: documentation of diagnosis of chronic osteomyelitis (e.g., ICD-10 M86.30–M86.69) and documentation that beads will be used in conjunction with intravenous antibiotics.

For allograft use in spinal fusion and osteochondral defects: documentation that clinical indication meets the selection criteria for spinal fusion per CPB 0743 (reference to CPB 0743 required) or documentation of osteochondral defect requiring bone void filler.

A59754 — Billing and Coding: Skin Substitute Grafts/Cellular and Tissue-Based Products for the Treatment of Diabetic Foot Ulcers and Venous Leg Ulcers

J09

A59731 — Billing and Coding: Skin Substitute Grafts/Cellular and Tissue-Based Products for the Treatment of Diabetic Foot Ulcers and Venous Leg Ulcers

J12

A59627 — Billing and Coding: Skin Substitutes Grafts/Cellular Tissue-Based Products for the Treatment of Diabetic Foot Ulcers and Venous Leg Ulcers

A59628 — Billing and Coding: Skin Substitutes Grafts/Cellular and Tissue-Based Products for the Treatment of Diabetic Foot Ulcers and Venous Leg Ulcers

A59690 — Billing and Coding: Skin Substitutes Grafts/Cellular Tissue-Based Products for the Treatment of Diabetic Foot Ulcers and Venous Leg Ulcers

A59691 — Billing and Coding: Skin Substitutes Grafts/Cellular Tissue-Based Products for the Treatment of Diabetic Foot Ulcers and Venous Leg Ulcers

AETNA-CPB-0411 — Bone and Tendon Graft Substitutes and Adjuncts

ANTHEM-CG-SURG-127 — CG-SURG-127 Products for Wound Healing and Soft Tissue Grafting: Medically Necessary Uses

AMBETTER-CP.MP.185 — Skin and Soft Tissue Substitutes for Diabetic Foot Ulcers and Venous Leg Ulcers

REGENCE-MED170 — Bioengineered Skin and Soft Tissue Substitutes and Amniotic Products

CIGNA-0068 — Tissue Engineered Skin Substitutes - (0068)

A59617 — Billing and Coding: Skin Substitutes Grafts/Cellular Tissue-Based Products for the Treatment of Diabetic Foot Ulcers and Venous Leg Ulcers

A59618 — Billing and Coding: Skin Substitutes Grafts/Cellular and Tissue-Based Products for the Treatment of Diabetic Foot Ulcers and Venous Leg Ulcers

A59625 — Billing and Coding: Skin Substitutes Grafts/Cellular Tissue-Based Products for the Treatment of Diabetic Foot Ulcers and Venous Leg Ulcers

A59626 — Billing and Coding: Skin Substitutes Grafts/Cellular and Tissue-Based Products for the Treatment of Diabetic Foot Ulcers and Venous Leg Ulcers

Q4116 — Alloderm, per square centimeter (add-on, list separately in addition to primary procedure)