Q4119, Matristem wound matrix, per square centimeter
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Documentation that the patient is under the care of a wound care physician or surgeon.
- Documentation that systemic disease (e.g., diabetes, venous insufficiency) is being monitored/treated to support adequate wound healing.
- Documentation of a non-infected wound at the treatment site.
- For DFU, documentation of the required clinical criteria referenced in the policy (policy text states "documentation of all the following" but full criteria details are not contained in this excerpt).
Key Coverage Criteria
- Use of skin substitute grafts for treatment of diabetic foot ulcers.
- Use of skin substitute grafts for treatment of venous leg ulcers.
- Use of skin substitutes for chronic wounds when managed as part of a wound care treatment plan.
- Up to four initial applications of skin and soft tissue substitutes/CTPs are medically necessary for diabetic foot ulcers (DFU) when there is a non-infected wound and required documentation criteria are met.
- Up to four initial applications of skin and soft tissue substitutes/CTPs are medically necessary for venous leg ulcers (VLU) when there is a non-infected wound and required documentation criteria are met.
- Failure to achieve at least 50% reduction in ulcer area after a minimum of four weeks of compliance with standard of care wound treatment.
1 Active Policy
AMBETTER-CP.MP.185, Skin and Soft Tissue Substitutes for Diabetic Foot Ulcers and Venous Leg Ulcers
Related Codes
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