C5273 prior authorization | Anthem Blue Cross and Blue Shield New Hampshire

C5273, Application of low cost skin substitute graft to trunk, arms, legs, total wound surface area greater than or equal to 100 sq cm; first 100 sq cm wound surface area, or 1% of body area of infants and children, is on the Anthem Blue Cross and Blue Shield New Hampshire prior authorization list. Not a coverage or referral decision.

Code: C5273
Description: Application of low cost skin substitute graft to trunk, arms, legs, total wound surface area greater than or equal to 100 sq cm; first 100 sq cm wound surface area, or 1% of body area of infants and children
Source: New Hampshire Precertification List, Pg 213 Original policy

Anthem Blue Cross and Blue Shield New Hampshire prior authorization

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