Q4116, Alloderm, per square centimeter (add-on, list separately in addition to primary
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
10 Active Policies
ANTHEM-CG-SURG-127, CG-SURG-127 Products for Wound Healing and Soft Tissue Grafting: Medically Necessary Uses
CIGNA-0068, Tissue Engineered Skin Substitutes
AETNA-CPB-0411, Bone and Tendon Graft Substitutes and Adjuncts
AMBETTER-CP.MP.185, Skin and Soft Tissue Substitutes for Diabetic Foot Ulcers and Venous Leg Ulcers
BCBSIL-SUR704.012
Related Codes
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