Q4126 prior authorization | Anthem Blue Cross and Blue Shield Virginia

Q4126, Memoderm, dermaspan, tranzgraft or integuply, per square centimeter (add-on, list separately in addition to primary procedure), is on the Anthem Blue Cross and Blue Shield Virginia HMO/EPO prior authorization list. Not a coverage or referral decision.

Code: Q4126
Description: Memoderm, dermaspan, tranzgraft or integuply, per square centimeter (add-on, list separately in addition to primary procedure)
Source: Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 75 Original policy

Anthem Blue Cross and Blue Shield Virginia prior authorization

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