Q4122 prior authorization | Blue Cross and Blue Shield of Montana

Q4122, Dermacell, dermacell awm or dermacell awm porous, per square centimeter (add- on, list separately in addition to primary procedure), is on the Blue Cross and Blue Shield of Montana commercial prior authorization list. Not a coverage or referral decision.

Code: Q4122
Description: Dermacell, dermacell awm or dermacell awm porous, per square centimeter (add- on, list separately in addition to primary procedure)
Source: 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 279 Original policy

Blue Cross and Blue Shield of Montana prior authorization

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