Anthem Blue Cross Blue Shield of California policy
CG-SURG-127 Products for Wound Healing and Soft Tissue Grafting: Medically Necessary Uses
CG-SURG-127 Products for Wound Healing and Soft Tissue Grafting: Medically Necessary Uses is a public Anthem Blue Cross Blue Shield of California policy (policy CG-SURG-127). It lists 77 CPT or HCPCS codes, 62 of them on the Anthem Blue Cross Blue Shield of California prior authorization list. Not a coverage decision; the payer's own document governs.
- Policy number
- CG-SURG-127
- Line of business
- Commercial
- Source
- www.anthem.com
Codes in this policy
The CPT and HCPCS codes the policy names. A policy can name a code it excludes. Prior authorization status is from the Anthem Blue Cross Blue Shield of California prior authorization list.
| Code | Prior authorization | Description on the prior authorization list | Other Anthem Blue Cross Blue Shield of California policies |
|---|---|---|---|
| 00007 | Not listed | Policies naming 00007 | |
| 00008 | Not listed | Policies naming 00008 | |
| 00011 | Not listed | Policies naming 00011 | |
| 00023 | Not listed | Policies naming 00023 | |
| 00035 | Not listed | Policies naming 00035 | |
| 00056 | Not listed | Policies naming 00056 | |
| 00110 | Not listed | Policies naming 00110 | |
| 00132 | Not listed | Policies naming 00132 | |
| 15011 | On the list | Harvest of skin for skin cell suspension autograft; first 25 sq cm or less | Policies naming 15011 |
| 15012 | On the list | Harvest of skin for skin cell suspension autograft; each additional 25 sq cm or part thereof | Policies naming 15012 |
| 15013 | On the list | Preparation of skin cell suspension autograft, requiring enzymatic processing, manual mechanical disaggregation of skin cells, and filtration; first 25 sq cm or less of harvested skin | Policies naming 15013 |
| 15014 | On the list | Preparation of skin cell suspension autograft, requiring enzymatic processing, manual mechanical disaggregation of skin cells, and filtration; each additional 25 sq cm of harvested skin or part thereof | Policies naming 15014 |
| 15015 | On the list | Application of skin cell suspension autograft to wound and donor sites, including application of primary dressing, trunk, arms, legs; first 480 sq cm or less | Policies naming 15015 |
| 15016 | On the list | Application of skin cell suspension autograft to wound and donor sites, including application of primary dressing, trunk, arms, legs; each additional 480 sq cm or part thereof | Policies naming 15016 |
| 15017 | On the list | Application of skin cell suspension autograft to wound and donor sites, including application of primary dressing, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 480 sq cm or less | Policies naming 15017 |
| 15018 | On the list | Application of skin cell suspension autograft to wound and donor sites, including application of primary dressing, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; each additional 480 sq cm or part thereof | Policies naming 15018 |
| 15150 | On the list | Tissue cultured skin autograft, trunk, arms, legs; first 25 sq cm or less | Policies naming 15150 |
| 15151 | On the list | Tissue cultured skin autograft, trunk, arms, legs; additional 1 sq cm to 75 sq cm | Policies naming 15151 |
| 15152 | On the list | Tissue cultured skin autograft, trunk, arms, legs; each additional 100 sq cm, or each additional 1% of body area of infants and children, or part thereof | Policies naming 15152 |
| 15155 | On the list | Tissue cultured skin autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 25 sq cm or less | Policies naming 15155 |
| 15156 | On the list | Tissue cultured skin autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; additional 1 sq cm to 75 sq cm | Policies naming 15156 |
| 15157 | On the list | Tissue cultured skin autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; each additional 100 sq cm, or each additional 1% of body area of infants and children, or part thereof | Policies naming 15157 |
| 15271 | On the list | Application of skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area | Policies naming 15271 |
| 15272 | On the list | Application of skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; each additional 25 sq cm wound surface area, or part thereof | Policies naming 15272 |
| 15273 | On the list | Application of 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 | Policies naming 15273 |
| 15274 | On the list | Application of skin substitute graft to trunk, arms, legs, total wound surface area greater than or equal to 100 sq cm; each additional 100 sq cm wound surface area, or part thereof, or each additional 1% of body area of infants and children, or part thereof | Policies naming 15274 |
| 15275 | On the list | Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area | Policies naming 15275 |
| 15276 | On the list | Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area up to 100 sq cm; each additional 25 sq cm wound surface area, or part thereof | Policies naming 15276 |
| 15277 | On the list | Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, 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 | Policies naming 15277 |
| 15278 | On the list | Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area greater than or equal to 100 sq cm; each additional 100 sq cm wound surface area, or part thereof, or each additional 1% of body area of infants and children, or part thereof | Policies naming 15278 |
| 15777 | On the list | Implantation of biologic implant (e.g., acellular dermal matrix) for soft tissue reinforcement (i.e., breast, trunk) | Policies naming 15777 |
| 17999 | On the list | Unlisted procedure, skin, mucous membrane and subcutaneous tissue [when specified as other abdominoplasty, excision excessive skin and subcutaneous tissue, including lipectomy, of abdomen] or [when specified as permanent hair removal by laser] or [when specified as implantation of biologic implants for soft tissue reinforcement in tissues other than breast and trunk] or [when specified as aesthetic flat chest closure or chest wall reconstruction after breast surgery] or [when specified as laser treatment of onychomycosis] or [when specified as percutaneous ultrasound ablation of subcutaneous tissue] or [when specified as application of prademagene zamikeracel (Zevaskyn) genetically engineered autologous cell therapy] or [when specified as harvesting or administration of stem cells for therapy to repair damaged cells or body tissues] | Policies naming 17999 |
| 65778 | On the list | Placement of amniotic membrane on the ocular surface; without sutures | Policies naming 65778 |
| 65779 | On the list | Placement of amniotic membrane on the ocular surface; single layer, sutured | Policies naming 65779 |
| 65780 | On the list | Ocular surface reconstruction; amniotic membrane transplantation, multiple layers | Policies naming 65780 |
| A2043 | On the list | NovaShield or NovoGen wound matrix, per square centimeter | Policies naming A2043 |
| A2044 | Not listed | Policies naming A2044 | |
| C1763 | On the list | Connective tissue, non-human (includes synthetic) [when specified as BioBrace Implant] | Policies naming C1763 |
| C1832 | On the list | Autograft suspension, including cell processing and application, and all system components | Policies naming C1832 |
| C8002 | On the list | Preparation of skin cell suspension autograft, automated, including all enzymatic processing and device components (do not report with manual suspension preparation) | Policies naming C8002 |
| C9358 | On the list | Dermal substitute, native, non-denatured collagen, fetal bovine origin (SurgiMend Collagen Matrix), per 0.5 square centimeters | Policies naming C9358 |
| C9360 | Not listed | Policies naming C9360 | |
| C9363 | On the list | Skin substitute, Integra Meshed Bilayer Wound Matrix, per square centimeter | Policies naming C9363 |
| C9399 | On the list | Unclassified drugs or biologicals [when specified as lifileucel (Amtagvi)] or [when specified as eladocagene exuparvovec- tneq (Kebilidi)] or [when specified as an ocular gene therapy agent other than voretigene neparvovec-rzyl (Luxturna)] or [when specified as etuvetidigene autotemcel (Waskyra)] or [when specified as a gene therapy for hemophilia other than Hemgenix, Beqvez, or Roctavian] or [when describing a product with no specific code indicated as investigational and not medically necessary] | Policies naming C9399 |
| Q4101 | On the list | Apligraf, per square centimeter | Policies naming Q4101 |
| Q4102 | On the list | Oasis Wound Matrix, per square centimeter | Policies naming Q4102 |
| Q4104 | On the list | Integra Bilayer Matrix Wound Dressing (BMWD), per square centimeter | Policies naming Q4104 |
| Q4105 | On the list | Integra Dermal Regeneration Template (DRT) or Integra Omnigraft dermal regeneration matrix, per square centimeter | Policies naming Q4105 |
| Q4107 | On the list | GraftJacket, per square centimeter | Policies naming Q4107 |
| Q4110 | On the list | PriMatrix, per square centimeter | Policies naming Q4110 |
| Q4115 | On the list | AlloSkin, per square centimeter | Policies naming Q4115 |
| Q4116 | On the list | AlloDerm, per square centimeter [AlloDerm RTM, AlloDerm RTU for breast reconstruction and abdominal wall wounds] | Policies naming Q4116 |
| Q4121 | On the list | TheraSkin, per square centimeter | Policies naming Q4121 |
| Q4122 | On the list | Dermacell, Dermacell AWM or Dermacell AWM porous, per square centimeter [for breast reconstruction or diabetic foot ulcers only] | Policies naming Q4122 |
| Q4124 | On the list | Oasis Ultra Tri-Layer Wound Matrix, per square centimeter | Policies naming Q4124 |
| Q4128 | On the list | FlexHD, or Allopatch HD, per sq cm [when specified as FlexHD for breast reconstruction] | Policies naming Q4128 |
| Q4130 | On the list | Strattice, per square centimeter [for breast reconstruction and abdominal wall wounds] | Policies naming Q4130 |
| Q4133 | On the list | Grafix PRIME, GrafixPL PRIME, Stravix and StravixPL, per square centimeter [when specified as Grafix PRIME, for diabetic foot ulcers only] or [when specified as GrafixPL PRIME, Stravix, StravixPL] | Policies naming Q4133 |
| Q4136 | Not listed | Policies naming Q4136 | |
| Q4151 | On the list | AmnioBand or Guardian, per sq cm [for diabetic foot ulcers only]] | Policies naming Q4151 |
| Q4154 | On the list | Biovance, per square centimeter | Policies naming Q4154 |
| Q4158 | On the list | Kerecis Omega3, per square centimeter | Policies naming Q4158 |
| Q4160 | On the list | NuShield, per square centimeter | Policies naming Q4160 |
| Q4182 | Not listed | Policies naming Q4182 | |
| Q4186 | On the list | EpiFix, per square centimeter | Policies naming Q4186 |
| Q4187 | On the list | EpiCord, per square centimeter [for diabetic foot ulcers only] | Policies naming Q4187 |
| Q4223 | Not listed | Policies naming Q4223 | |
| Q4283 | On the list | Biovance Tri-layer or Biovance 3L, per square centimeter | Policies naming Q4283 |
| Q4334 | On the list | AmnioPlast 1, per square centimeter | Policies naming Q4334 |
| Q4335 | On the list | AmnioPlast 2, per square centimeter | Policies naming Q4335 |
| Q4369 | On the list | AmnioPlast 3, per square centimeter | Policies naming Q4369 |
| Q4391 | Not listed | Policies naming Q4391 | |
| Q4410 | Not listed | Policies naming Q4410 | |
| Q4431 | On the list | PMA skin substitute product, not otherwise specified [when describing a product with no specific code indicated as investigational and not medically necessary] | Policies naming Q4431 |
| Q4432 | On the list | 510(k) skin substitute product, not otherwise specified [when describing a product with no specific code indicated as investigational and not medically necessary] | Policies naming Q4432 |
| Q4433 | On the list | 361 HCT/P skin substitute product, not otherwise specified [when describing a product with no specific code indicated as investigational and not medically necessary] | Policies naming Q4433 |
| V2790 | On the list | Amniotic membrane for surgical reconstruction, per procedure | Policies naming V2790 |
All Anthem Blue Cross Blue Shield of California policies · Anthem Blue Cross Blue Shield of California prior authorization CPT list