G0681 prior authorization | Blue Shield of California Promise Health Plan

G0681, Application of a premarket approval (PMA), 510(k), 361 human cells, tissues or cellular and tissue-based products (HCT/P) nonsheet form skin substitute for a wound surface area up to 100 sq cm; first 25 sq cm or less of wound surface area, is on the Blue Shield of California Promise Health Plan Medi-Cal prior authorization list. Not a coverage or referral decision.

Code: G0681
Description: Application of a premarket approval (PMA), 510(k), 361 human cells, tissues or cellular and tissue-based products (HCT/P) nonsheet form skin substitute for a wound surface area up to 100 sq cm; first 25 sq cm or less of wound surface area
Source: Medi-Cal Prior Authorization List, Pg 26 Original policy

Blue Shield of California Promise Health Plan prior authorization

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