Effective October 1, 2025: New Prior Authorization Requirement for Certain Chronic Wound Skin and Soft Tissue Substitutes

Procedure Code

Description

Criteria

Q4111

Gammagraft, per sq cm

CP.MP.185 Skin and Soft Tissue Substitutes for Chronic Wounds

For more information view, Superior’s Clinical, Payment & Pharmacy Polices.

A2014

Omeza Collagen Matrix, per 100 mg

A2015

Phoenix Wound Matrix, per sq cm

A2016

PermeaDerm B, per sq cm

A2017

PermeaDerm Glove, each

A2018

PermeaDerm C, per sq cm

Q4259

Celera Dual Layer or Celera Dual Membrane, per sq cm

Q4260

Signature Apatch, per sq cm

Q4261

TAG, per sq cm

Q4266

NeoStim Membrane, per sq cm

Procedure Code

Description

Criteria

Q4101

Apligraf, per sq cm

CP.MP.185 Skin and Soft Tissue Substitutes for Chronic Wounds

For more information view, Superior’s Clinical, Payment & Pharmacy Polices.

Q4102

Oasis wound matrix, per sq cm 

Q4106

Dermagraft, per sq cm

Q4110

PriMatrix, per sq cm

Q4121

TheraSkin, per sq cm

Q4124

Oasis ultra tri-layer wound matrix, per sq cm

Q4128

FlexHD, or AllopatchHD, per sq cm

Q4133

Grafix PRIME, GrafixPL PRIME, Stravix and StravixPL, per sq cm

Q4141

AlloSkin AC, per sq cm

Q4146

TENSIX, per sq cm

Q4148

Neox Cord 1K, Neox Cord RT, or Clarix Cord 1K, per sq cm

Q4151

AmnioBand or Guardian, per sq cm

Q4154

Biovance, per sq cm

Q4160

Nushield, per sq cm

Q4178

FlowerAmnioPatch, per sq cm

Q4186

Epifix, per sq cm

Q4187

Epicord, per sq cm

Q4195

PuraPly, per square cm

Q4196

PuraPly AM , per square cm

Q4253

Zenith amniotic membrane, per sq cm

C9360

Dermal substitute, native, nondenatured collagen, neonatal bovine origin (SurgiMend Collagen Matrix), per 0.5 sq cm

Q4106

Dermagraft, per sq cm

Q4113

GRAFTJACKET XPRESS, injectable, 1 cc

Q4122

DermACELL, DermACELL AWM or DermACELL AWM Porous, per sq cm

Q4123

AlloSkin RT, per sq cm

Q4126

MemoDerm, DermaSpan, TranZgraft or Integuply, per sq cm

Q4127

Talymed, per sq cm

Q4134

Hmatrix, per sq cm

Q4135

Mediskin, per sq cm

Q4138

BioDFence DryFlex, per sq cm

Q4140

BioDFence, per sq cm

Q4142

XCM biologic tissue matrix, per sq cm

Q4143

Repriza, per sq cm

Q4145

EpiFix, injectable, 1 mg

Q4147

Architect, Architect PX, or Architect FX, extracellular matrix, per sq cm

Q4149

Excellagen, 0.1 cc

Q4165

Keramatrix or Kerasorb, per sq cm

Q4173

Palingen or Palingen Xplus, per sq cm

Q4174

PalinGen or ProMatrX, 0.36 mg per 0.25 cc

Q4176

Neopatch or therion, per sq cm

Q4177

FlowerAmnioFlo, 0.1 cc

Q4179

FlowerDerm, per sq cm

Q4180

Revita, per sq cm

Q4182

Transcyte, per sq cm

Q4246

CoreText or ProText, per cc

Q4249

AMNIPLY, for topical use only, per sq cm

Q4250

AmnioAmp-MP, per sq cm

Q4251

Vim, per sq cm

Q4252

Vendaje, per sq cm

Q4254

Novafix, per sq cm

Q4255

REGUaRD, for topical use only, per sq cm

Q4368 

AmchoThick, per sq cm

Q4369 

AmnioPlast 3, per sq cm

Q4370 

AeroGuard, per sq cm

Q4371 

NeoGuard, per sq cm

Q4372 

AmchoPlast EXCEL, per sq cm

Q4373 

Membrane Wrap-Lite, per sq cm

Q4375 

DuoGRAFT AC, per sq cm

Q4376 

DuoGRAFT AA, per sq cm

Q4377 

TriGraft FT, per sq cm

Q4378 

Renew FT Matrix, per sq cm

Q4379 

AmnioDefend FT Matrix, per sq cm

Q4380 

AdvoGraft One, per sq cm

Q4382 

Advograft Dual, per sq cm

Procedure Code

Description

Criteria

Q4104

Integra bilayer matrix wound dressing (BMWD), per sq cm

CP.MP.185 Skin and Soft Tissue Substitutes for Chronic Wounds

For more information view, Superior’s Clinical, Payment & Pharmacy Polices.

Q4105

Integra dermal regeneration template (DRT) or Integra Omnigraft dermal regeneration matrix, per sq cm

Q4115

Alloskin, per sq cm

Q4117

Hyalomatrix, per sq cm

Q4118

Matristem micromatrix, 1mg

Q4132

Grafix Core and GrafixPL Core, per sq cm

Q4152

DermaPure, per sq cm

Q4156

Neox 100 or Clarix 100, per sq cm

Q4158

Kerecis Omega3, per sq cm

Q4159

Affinity, per sq cm

Q4166

Cytal, per square centimeter

Q4170

Cygnus, per sq cm

Q4175

Miroderm, per sq cm

Q4188

AmnioArmor, per sq cm

Q4197

Puraply XT, per square cm

Q4201

Matrion, per sq cm

Q4203

Derma-Gide, per sq cm

C9358

Dermal substitute, native, nondenatured collagen, fetal bovine origin (SurgiMend Collagen Matrix), per 0.5 sq cm

C9363

Skin substitute (Integra Meshed Bilayer Wound Matrix), per sq cm

C9364

Porcine implant, Permacol, per sq cm

Q4100

Skin substitute, not otherwise specified

Q4103

Oasis burn matrix, per sq cm

Q4104

Integra bilayer matrix wound dressing (BMWD), per sq cm

Q4108

Integra matrix, per sq cm

Q4112

Cymetra, injectable, 1 cc

Q4114

Integra flowable wound matrix, injectable, 1 cc

Q4116

AlloDerm, per sq cm

Q4125

ArthroFlex, per sq cm

Q4130

Strattice TM, per sq cm

Q4136

E Z Derm, per sq cm

Q4150

AlloWrap DS or dry, per sq cm

Q4153

Dermavest and Plurivest, per sq cm

Q4155

Neox Flo or Clarix Flo 1 mg

Q4157

Revitalon, per sq cm

Q4161

Bio-connekt wound matrix, per sq cm

Q4162

WoundEx Flow, BioSkin Flow, 0.5 cc

Q4163

Woundex, bioskin, per sq cm

Q4164

Helicoll, per sq cm

Q4167

Truskin, per sq cm

Q4168

AmnioBand, 1 mg

Q4169

Artacent wound, per sq cm

Q4171

Interfyl, 1 mg

Q4181

Amnio Wound, per sq cm

Q4183

Surgigraft, per sq cm

Q4184

Cellesta or Cellesta Duo, per sq cm

Q4185

Cellesta Flowable Amnion (25 mg per cc); per 0.5 cc

Q4189

Artacent AC, 1 mg

Q4190

Artacent AC, per sq cm

Q4191

Restorigin, per sq cm

Q4192

Restorigin, 1 cc

Q4193

Coll-e-Derm, per sq cm

Q4194

Novachor, per sq cm

Q4198

Genesis Amniotic Membrane, per sq cm

Q4200

SkinTE, per sq cm

Q4202

Keroxx (2.5 g/cc), 1 cc

Q4204

XWRAP, per sq cm

Q4205

Membrane Graft or Membrane Wrap, per sq cm

Q4206

Fluid Flow or Fluid GF, 1 cc

Q4208

Novafix, per sq cm

Q4209

SurGraft, per sq cm

Q4211

Amnion Bio or AxoBioMembrane, per sq cm

Q4212

AlloGen, per cc

Q4214

Cellesta Cord, per sq cm

Q4215

Axolotl Ambient or Axolotl Cryo, 0.1 mg

Q4216

Artacent Cord, per sq cm

Q4217

WoundFix, BioWound, WoundFix Plus, BioWound Plus, WoundFix Xplus or BioWound Xplus, per sq cm

Q4218

SurgiCORD, per sq cm

Q4219

SurgiGRAFT-DUAL, per sq cm

Q4220

BellaCell HD or Surederm, per sq cm

Q4221

Amnio Wrap2, per sq cm

Q4222

ProgenaMatrix, per sq cm

Q4226

MyOwn Skin, includes harvesting and preparation procedures, per sq cm

Q4227

AmnioCore TM, per sq cm

Q4229

Cogenex Amniotic Membrane, per sq cm

Q4230

Cogenex Flowable Amnion, per 0.5 cc

Q4232

Corplex, per sq cm

Q4233

SurFactor or NuDyn, per 0.5 cc

Q4234

Xcellerate, per sq cm

Q4235

AMNIOREPAIR or AltiPly, per sq cm

Q4237

Cryo-Cord, per sq cm

Q4238

Derm-Maxx, per sq cm

Q4239

Amnio-Maxx or Amnio-Maxx Lite, per sq cm

Q4240

CoreCyte, for topical use only, per 0.5 cc

Q4241

PolyCyte, for topical use only, per 0.5 cc

Q4242

AmnioCyte Plus, per 0.5 cc

Q4245

AmnioText, per cc

Q4247

Amniotext patch, per sq cm

Q4248

Dermacyte Amniotic Membrane Allograft, per sq cm

Q4334

AmnioPlast 1, per sq cm

Q4335

AmnioPlast 2, per sq cm