S0305
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Key Coverage Criteria
- The following products are consideredmedically necessaryfor the treatment of diabetic foot ulcers when the clinical criteria below have been met:
- The following products are consideredmedically necessarywhen used for breast reconstruction surgery:
- AlloDerm Regenerative Tissue Matrix (aseptic or sterile);or
- Cortiva®;or
- DermACELLâ¢;or
- DermaMatrix®;or
1 Active Policy
ANTHEM-CG-SURG-127 — CG-SURG-127 Products for Wound Healing and Soft Tissue Grafting: Medically Necessary Uses
Related Codes
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