Q4105 prior authorization | Anthem Blue Cross Blue Shield of Georgia

Q4105, Integra Dermal Regeneration Template (DRT) or Integra Omnigraft dermal regeneration matrix, per square centimeter, is on the Anthem Blue Cross Blue Shield of Georgia prior authorization list. Not a coverage or referral decision.

Code: Q4105
Description: Integra Dermal Regeneration Template (DRT) or Integra Omnigraft dermal regeneration matrix, per square centimeter
Source: Standard Local Prior Authorization Code List, Pg 90 Original policy

Anthem Blue Cross Blue Shield of Georgia prior authorization

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