Q4105 prior authorization | Anthem Blue Cross and Blue Shield New Hampshire

Q4105, Integra dermal regeneration template (DRT) or Integra Omnigraft dermal regeneration matrix, per sq cm, is on the Anthem Blue Cross and Blue Shield New Hampshire prior authorization list. Not a coverage or referral decision.

Code: Q4105
Description: Integra dermal regeneration template (DRT) or Integra Omnigraft dermal regeneration matrix, per sq cm
Source: New Hampshire Precertification List, Pg 254 Original policy

Anthem Blue Cross and Blue Shield New Hampshire prior authorization

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