Anthem Blue Cross and Blue Shield Virginia 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 and Blue Shield Virginia policy (policy CG-SURG-127). It lists 77 CPT or HCPCS codes, 44 of them on the Anthem Blue Cross and Blue Shield Virginia 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 and Blue Shield Virginia prior authorization list.
| Code | Prior authorization | Description on the prior authorization list | Other Anthem Blue Cross and Blue Shield Virginia 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 autograft; first | Policies naming 15011 |
| 15012 | Not listed | Policies naming 15012 | |
| 15013 | On the list | Preparation of skin autograft, requiring enzymatic processing,; first 25 sq cm or less | Policies naming 15013 |
| 15014 | Not listed | Policies naming 15014 | |
| 15015 | On the list | Application of skin autograft; first 480 sq cm or less | Policies naming 15015 |
| 15016 | Not listed | Policies naming 15016 | |
| 15017 | On the list | Application of skin autograft; first 480 sq cm or less | Policies naming 15017 |
| 15018 | Not listed | 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 (List separately in addition to code for primary procedure) | Policies naming 15151 |
| 15152 | Not listed | 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 | Not listed | Policies naming 15156 | |
| 15157 | Not listed | 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 | Not listed | 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 | Policies naming 15273 |
| 15274 | Not listed | 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 | Policies naming 15275 |
| 15276 | Not listed | 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 | Policies naming 15277 |
| 15278 | Not listed | Policies naming 15278 | |
| 15777 | Not listed | Policies naming 15777 | |
| 17999 | Not listed | 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 | Not listed | Policies naming A2043 | |
| A2044 | Not listed | Policies naming A2044 | |
| C1763 | On the list | Connective tissue, nonhuman (includes synthetic) | 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, nondenatured collagen, fetal bovine origin (SurgiMend Collagen Matrix), per 0.5 sq cm | Policies naming C9358 |
| C9360 | Not listed | Policies naming C9360 | |
| C9363 | On the list | Skin substitute (Integra Meshed Bilayer Wound Matrix), per square cm | Policies naming C9363 |
| C9399 | Not listed | Policies naming C9399 | |
| Q4101 | On the list | Apligraf, per square centimeter (add-on, list separately in addition to primary procedure) | Policies naming Q4101 |
| Q4102 | On the list | Oasis wound matrix, per square centimeter (add-on, list separately in addition to primary procedure) | Policies naming Q4102 |
| Q4104 | On the list | Integra bilayer matrix wound dressing (bmwd), per square centimeter (add-on, list separately in addition to primary procedure) | Policies naming Q4104 |
| Q4105 | On the list | Integra dermal regeneration template (drt) or integra omnigraft dermal regeneration matrix, per square centimeter (add-on, list separately in addition to primary procedure) | Policies naming Q4105 |
| Q4107 | On the list | Graftjacket, per square centimeter (add-on, list separately in addition to primary procedure) | Policies naming Q4107 |
| Q4110 | On the list | Primatrix, per square centimeter (add-on, list separately in addition to primary procedure) | Policies naming Q4110 |
| Q4115 | On the list | Alloskin, per square centimeter (add-on, list separately in addition to primary procedure) | Policies naming Q4115 |
| Q4116 | On the list | Alloderm, per square centimeter (add-on, list separately in addition to primary procedure) | Policies naming Q4116 |
| Q4121 | On the list | Theraskin, per square centimeter (add-on, list separately in addition to primary procedure) | Policies naming Q4121 |
| Q4122 | On the list | Dermacell, dermacell awm or dermacell awm porous, per square centimeter (add-on, list separately in addition to primary procedure) | Policies naming Q4122 |
| Q4124 | On the list | Oasis ultra tri-layer wound matrix, per square centimeter (add-on, list separately in addition to primary procedure) | Policies naming Q4124 |
| Q4128 | On the list | Flex hd, or allopatch hd, per square centimeter (add-on, list separately in addition to primary procedure) | Policies naming Q4128 |
| Q4130 | On the list | Strattice tm, per square centimeter (add-on, list separately in addition to primary procedure) | Policies naming Q4130 |
| Q4133 | On the list | Grafix prime, grafixpl prime, stravix and stravixpl, per square centimeter (add-on, list separately in addition to primary procedure) | Policies naming Q4133 |
| Q4136 | Not listed | Policies naming Q4136 | |
| Q4151 | On the list | Amnioband or guardian, per square centimeter (add-on, list separately in addition to primary procedure) | Policies naming Q4151 |
| Q4154 | On the list | Biovance, per square centimeter (add-on, list separately in addition to primary procedure) | Policies naming Q4154 |
| Q4158 | On the list | Kerecis omega3, per square centimeter (add-on, list separately in addition to primary procedure) | Policies naming Q4158 |
| Q4160 | On the list | Nushield, per square centimeter (add-on, list separately in addition to primary procedure) | Policies naming Q4160 |
| Q4182 | Not listed | Policies naming Q4182 | |
| Q4186 | On the list | Epifix, per square centimeter (add-on, list separately in addition to primary procedure) | Policies naming Q4186 |
| Q4187 | On the list | Epicord, per square centimeter (add-on, list separately in addition to primary procedure) | Policies naming Q4187 |
| Q4223 | Not listed | Policies naming Q4223 | |
| Q4283 | On the list | Biovance tri-layer or biovance 3l, per square centimeter (add-on, list separately in addition to primary procedure) | Policies naming Q4283 |
| Q4334 | On the list | Amnioplast 1, per square centimeter (add-on, list separately in addition to primary procedure) | Policies naming Q4334 |
| Q4335 | On the list | Amnioplast 2, per square centimeter (add-on, list separately in addition to primary procedure) | Policies naming Q4335 |
| Q4369 | On the list | Amnioplast 3, per square centimeter (add-on, list separately in addition to primary procedure) | Policies naming Q4369 |
| Q4391 | Not listed | Policies naming Q4391 | |
| Q4410 | Not listed | Policies naming Q4410 | |
| Q4431 | Not listed | Policies naming Q4431 | |
| Q4432 | Not listed | Policies naming Q4432 | |
| Q4433 | Not listed | Policies naming Q4433 | |
| V2790 | On the list | Amniotic Membrane | Policies naming V2790 |
All Anthem Blue Cross and Blue Shield Virginia policies · Anthem Blue Cross and Blue Shield Virginia prior authorization CPT list