Anthem Blue Cross Blue Shield of California policy
SURG.00011 Products for Wound Healing and Soft Tissue Grafting: Investigational
SURG.00011 Products for Wound Healing and Soft Tissue Grafting: Investigational is a public Anthem Blue Cross Blue Shield of California policy (policy SURG.00011). It lists 377 CPT or HCPCS codes, 365 of them on the Anthem Blue Cross Blue Shield of California prior authorization list. Not a coverage decision; the payer's own document governs.
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- Policy number
- SURG.00011
- 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 Blue Shield of California prior authorization list.
| Code | Prior authorization | Description on the prior authorization list | Other Anthem Blue Cross Blue Shield of California policies |
|---|---|---|---|
| 00004 | Not listed | Policies naming 00004 | |
| 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 | |
| 00074 | Not listed | Policies naming 00074 | |
| 00110 | Not listed | Policies naming 00110 | |
| 00132 | Not listed | Policies naming 00132 | |
| 1044T | On the list | Harvest of full-thickness skin for autologous heterogeneous skin-construct graft, including direct closure of donor site; first 5 sq cm or less | Policies naming 1044T |
| 1045T | On the list | Harvest of full-thickness skin for autologous heterogeneous skin-construct graft, including direct closure of donor site; each additional 5 sq cm, or part thereof | Policies naming 1045T |
| 1046T | On the list | Autologous heterogeneous skin-construct graft application, trunk, arms, legs; first 50 sq cm or less, or 0.5% of body area of infants and children | Policies naming 1046T |
| 1047T | On the list | Autologous heterogeneous skin-construct graft application, trunk, arms, legs; each additional 50 sq cm, or each additional 0.5% of body area of infants and children, or part thereof | Policies naming 1047T |
| 1048T | On the list | Autologous heterogeneous skin-construct graft application, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 50 sq cm or less, or 0.5% of body area of infants and children | Policies naming 1048T |
| 1049T | On the list | Autologous heterogeneous skin-construct graft application, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; each additional 50 sq cm, or each additional 0.5% of body area of infants and children, or part thereof | Policies naming 1049T |
| 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 | Policies naming 15151 |
| 15152 | On the list | Tissue cultured skin autograft, trunk, arms, legs; each additional 100 sq cm, or each additional 1% of body area of infants and children, or part thereof | 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 | On the list | Tissue cultured skin autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; additional 1 sq cm to 75 sq cm | Policies naming 15156 |
| 15157 | On the list | Tissue cultured skin autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; each additional 100 sq cm, or each additional 1% of body area of infants and children, or part thereof | 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 | On the list | Application of skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; each additional 25 sq cm wound surface area, or part thereof | 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 of infants and children | Policies naming 15273 |
| 15274 | On the list | Application of skin substitute graft to trunk, arms, legs, total wound surface area greater than or equal to 100 sq cm; each additional 100 sq cm wound surface area, or part thereof, or each additional 1% of body area of infants and children, or part thereof | 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 cm; first 25 sq cm or less wound surface area | Policies naming 15275 |
| 15276 | 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 cm; each additional 25 sq cm wound surface area, or part thereof | 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 or equal to 100 sq cm; first 100 sq cm wound surface area, or 1% of body area of infants and children | Policies naming 15277 |
| 15278 | 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 or equal to 100 sq cm; each additional 100 sq cm wound surface area, or part thereof, or each additional 1% of body area of infants and children, or part thereof | Policies naming 15278 |
| 15777 | On the list | Implantation of biologic implant (e.g., acellular dermal matrix) for soft tissue reinforcement (i.e., breast, trunk) | Policies naming 15777 |
| 17999 | On the list | Unlisted procedure, skin, mucous membrane and subcutaneous tissue [when specified as other abdominoplasty, excision excessive skin and subcutaneous tissue, including lipectomy, of abdomen] or [when specified as permanent hair removal by laser] or [when specified as implantation of biologic implants for soft tissue reinforcement in tissues other than breast and trunk] or [when specified as aesthetic flat chest closure or chest wall reconstruction after breast surgery] or [when specified as laser treatment of onychomycosis] or [when specified as percutaneous ultrasound ablation of subcutaneous tissue] or [when specified as application of prademagene zamikeracel (Zevaskyn) genetically engineered autologous cell therapy] or [when specified as harvesting or administration of stem cells for therapy to repair damaged cells or body tissues] | Policies naming 17999 |
| 29999 | On the list | Unlisted procedure, arthroscopy [when specified as a tendon repair using BioBrace implant] or [when specified as thermal capsulorrhaphy of shoulder; elbow, wrist, hip, knee or ankle] or [when specified as surgery using Coblation technology] | Policies naming 29999 |
| 46707 | On the list | Repair of anorectal fistula with plug (e.g., porcine small intestine submucosa [SIS]) | Policies naming 46707 |
| A2001 | On the list | Innovamatrix AC, per square centimeter | Policies naming A2001 |
| A2002 | On the list | Mirragen advanced wound matrix, per square centimeter | Policies naming A2002 |
| A2004 | On the list | Xcellistem, 1mg | Policies naming A2004 |
| A2005 | On the list | Microlyte matrix, per square centimeter | Policies naming A2005 |
| A2006 | On the list | Novosorb synpath dermal matrix, per square centimeter | Policies naming A2006 |
| A2007 | On the list | Restrata, per square centimeter | Policies naming A2007 |
| A2008 | On the list | TheraGenesis, per square centimeter | Policies naming A2008 |
| A2009 | On the list | Symphony, per square centimeter | Policies naming A2009 |
| A2010 | On the list | Apis, per square centimeter | Policies naming A2010 |
| A2011 | On the list | Supra SDRM, per square centimeter | Policies naming A2011 |
| A2012 | On the list | Suprathel, per square centimeter | Policies naming A2012 |
| A2013 | On the list | InnovaMatrix FS, per square centimeter | Policies naming A2013 |
| A2014 | On the list | Omeza Collagen Matrix, per 100 mg | Policies naming A2014 |
| A2015 | On the list | Phoenix Wound Matrix, per sq cm | Policies naming A2015 |
| A2016 | On the list | PermeaDerm B, per sq cm | Policies naming A2016 |
| A2017 | On the list | PermeaDerm Glove, each | Policies naming A2017 |
| A2018 | On the list | PermeaDerm C, per sq cm | Policies naming A2018 |
| A2019 | On the list | Kerecis omega3 MariGen Shield, per square centimeter | Policies naming A2019 |
| A2020 | On the list | Ac5 advanced wound system (Ac5) | Policies naming A2020 |
| A2021 | On the list | NeoMatriX, per square centimeter | Policies naming A2021 |
| A2022 | On the list | InnovaBurn or InnovaMatrix XL, per square centimeter | Policies naming A2022 |
| A2023 | On the list | InnovaMatrix PD 1 mg | Policies naming A2023 |
| A2024 | On the list | Resolve Matrix or xenoPATCH, per square centimeter | Policies naming A2024 |
| A2025 | On the list | Miro3D, per cubic centimeter | Policies naming A2025 |
| A2026 | On the list | Restrata MiniMatrix, 5 mg | Policies naming A2026 |
| A2027 | On the list | Matriderm, per square centimeter | Policies naming A2027 |
| A2028 | On the list | MicroMatrix Flex, per mg | Policies naming A2028 |
| A2029 | On the list | MiroTract Wound Matrix sheet, per cubic centimeter | Policies naming A2029 |
| A2030 | On the list | Miro3D fibers, per milligram | Policies naming A2030 |
| A2031 | On the list | MiroDry wound matrix, per square centimeter | Policies naming A2031 |
| A2032 | On the list | Myriad matrix, per square centimeter | Policies naming A2032 |
| A2033 | On the list | Myriad morcells, 4 milligrams | Policies naming A2033 |
| A2034 | On the list | Foundation DRS Solo, per sq cm | Policies naming A2034 |
| A2035 | On the list | Corplex P or Theracor P or Allacor P, per milligram | Policies naming A2035 |
| A2036 | On the list | Cohealyx collagen dermal matrix, per square centimeter | Policies naming A2036 |
| A2037 | On the list | G4Derm Plus, per milliliter | Policies naming A2037 |
| A2038 | On the list | Marigen Pacto, per square centimeter | Policies naming A2038 |
| A2039 | On the list | Innovamatrix FD, per square centimeter | Policies naming A2039 |
| A2040 | On the list | Microlyte Painguard, per square centimeter | Policies naming A2040 |
| A2041 | On the list | Foundation DRS+ Duo, per square centimeter | Policies naming A2041 |
| A2042 | On the list | Foundation DRS+ Solo, per square centimeter | Policies naming A2042 |
| A2045 | Not listed | Policies naming A2045 | |
| A4100 | Not listed | Policies naming A4100 | |
| C1763 | On the list | Connective tissue, non-human (includes synthetic) [when specified as BioBrace Implant] | Policies naming C1763 |
| C9354 | On the list | Acellular pericardial tissue matrix of non-human origin (Veritas), per square centimeter | Policies naming C9354 |
| C9356 | On the list | Tendon, porous matrix of cross-linked collagen and glycosaminoglycan matrix (TenoGlide Tendon Protector Sheet), per square centimeter | Policies naming C9356 |
| C9364 | On the list | Porcine implant, Permacol, per square centimeter | Policies naming C9364 |
| C9399 | On the list | Unclassified drugs or biologicals [when specified as lifileucel (Amtagvi)] or [when specified as eladocagene exuparvovec- tneq (Kebilidi)] or [when specified as an ocular gene therapy agent other than voretigene neparvovec-rzyl (Luxturna)] or [when specified as etuvetidigene autotemcel (Waskyra)] or [when specified as a gene therapy for hemophilia other than Hemgenix, Beqvez, or Roctavian] or [when describing a product with no specific code indicated as investigational and not medically necessary] | Policies naming C9399 |
| C9796 | On the list | Repair of enterocutaneous fistula small intestine or colon (excluding anorectal fistula) with plug (e.g., porcine small intestine submucosa [sis]) | Policies naming C9796 |
| G0428 | On the list | Collagen meniscus implant procedure for filling meniscal defects (e.g., CMI, collagen scaffold, Menaflex) | Policies naming G0428 |
| G0681 | On the list | Application of a premarket approval (PMA), 510(k), 361 human cells, tissues or cellular and tissue-based products (HCT/P) non-sheet form skin substitute for a wound surface area up to 100 sq cm; first 25 sq cm or less of wound surface area | Policies naming G0681 |
| G0682 | On the list | Application of a premarket approval (PMA), 510(k), 361 human cells, tissues or cellular and tissue-based products (HCT/P) non-sheet form skin substitute for a wound surface area up to 100 sq cm; each additional 25 sq cm wound surface area, or part thereof | Policies naming G0682 |
| G0683 | On the list | Application of a premarket approval (PMA), 510(k), 361 human cells, tissues or cellular and tissue-based products (HCT/P) non-sheet form skin substitute graft for a wound surface greater than or equal to 100 sq cm; first 100 sq cm wound surface area, or 1% of body area of infants and children | Policies naming G0683 |
| G0684 | On the list | Application of a premarket approval (PMA), 510(k), 361 human cells, tissues or cellular and tissue-based products (HCT/P) non-sheet form skin substitute graft for a wound surface greater than or equal to 100 sq cm; each additional 100 sq cm wound surface area or part thereof, or each additional 1% of body area of infants and children, or part thereof | Policies naming G0684 |
| Q4103 | On the list | Oasis Burn Matrix, per square centimeter | Policies naming Q4103 |
| Q4108 | On the list | Integra Matrix, per square centimeter | Policies naming Q4108 |
| Q4111 | On the list | Gammagraft, per square centimeter | Policies naming Q4111 |
| Q4113 | Not listed | Policies naming Q4113 | |
| Q4114 | On the list | Integra Flowable Wound Matrix, injectable, 1 cc | Policies naming Q4114 |
| Q4117 | On the list | Hyalomatrix, per square centimeter | Policies naming Q4117 |
| Q4118 | On the list | Matristem micromatrix, 1 mg | Policies naming Q4118 |
| Q4123 | On the list | AlloSkin RT, per square centimeter | Policies naming Q4123 |
| Q4125 | On the list | ArthroFlex, per square centimeter | Policies naming Q4125 |
| Q4126 | On the list | Memoderm, dermaspan, tranzgraft or integuply, per square centimeter | Policies naming Q4126 |
| Q4127 | On the list | Talymed, per square centimeter | Policies naming Q4127 |
| Q4132 | On the list | Grafix CORE and GrafixPL CORE, per square centimeter | Policies naming Q4132 |
| Q4134 | On the list | hMatrix, per square centimeter | Policies naming Q4134 |
| Q4135 | On the list | Mediskin, per square centimeter | Policies naming Q4135 |
| Q4137 | On the list | AmnioExCel, AmnioExCel plus or BioDExCel, per square centimeter | Policies naming Q4137 |
| Q4138 | On the list | BioDfence Dryflex, per square centimeter | Policies naming Q4138 |
| Q4139 | On the list | AmnioMatrix or BioDMatrix, injectable, 1 cc | Policies naming Q4139 |
| Q4140 | On the list | BioDfence, per square centimeter | Policies naming Q4140 |
| Q4141 | On the list | Alloskin AC, per square centimeter | Policies naming Q4141 |
| Q4142 | On the list | XCM Biologic Tissue Matrix, per square centimeter | Policies naming Q4142 |
| Q4143 | On the list | Repriza, per square centimeter | Policies naming Q4143 |
| Q4145 | On the list | Epifix, injectable, 1 mg | Policies naming Q4145 |
| Q4146 | On the list | TenSIX, per square centimeter | Policies naming Q4146 |
| Q4147 | On the list | Architect, Architect PX, or Architect FX, extracellular matrix, per square centimeter | Policies naming Q4147 |
| Q4148 | On the list | NEOX Cord 1k, NEOX Cord RT, or Clarix Cord 1k, per square centimeter | Policies naming Q4148 |
| Q4149 | On the list | Excellagen, 0.1 cc | Policies naming Q4149 |
| Q4150 | On the list | Allowrap DS or Dry, per square centimeter | Policies naming Q4150 |
| Q4152 | On the list | DermaPure, per square centimeter | Policies naming Q4152 |
| Q4153 | On the list | Dermavest and Plurivest, per square centimeter | Policies naming Q4153 |
| Q4155 | On the list | NeoxFlo or ClarixFlo, 1 mg | Policies naming Q4155 |
| Q4156 | On the list | NEOX 100 or Clarix 100, per square centimeter | Policies naming Q4156 |
| Q4157 | On the list | Revitalon, per square centimeter | Policies naming Q4157 |
| Q4159 | On the list | Affinity, per square centimeter | Policies naming Q4159 |
| Q4161 | On the list | Bio-connekt wound matrix, per square centimeter | Policies naming Q4161 |
| Q4162 | On the list | WoundEx Flow, BioSkin Flow, 0.5 cc | Policies naming Q4162 |
| Q4163 | On the list | WoundEx, BioSkin, per square centimeter | Policies naming Q4163 |
| Q4164 | On the list | Helicoll, per square centimeter | Policies naming Q4164 |
| Q4165 | On the list | Keramatrix or Kerasorb, per square centimeter | Policies naming Q4165 |
| Q4166 | On the list | Cytal, per square centimeter [formerly Matristem wound/burn matrix] | Policies naming Q4166 |
| Q4167 | On the list | TruSkin, per square centimeter | Policies naming Q4167 |
| Q4169 | On the list | Artacent Wound, per square centimeter | Policies naming Q4169 |
| Q4170 | On the list | CYGNUS, per square centimeter | Policies naming Q4170 |
| Q4171 | On the list | Interfyl, 1 mg | Policies naming Q4171 |
| Q4173 | On the list | PalinGen or PalinGen Xplus, per square centimeter | Policies naming Q4173 |
| Q4174 | On the list | PalinGen or ProMatrX, 0.36 mg per 0.25 cc | Policies naming Q4174 |
| Q4175 | On the list | Miroderm, per square centimeter | Policies naming Q4175 |
| Q4176 | On the list | NeoPatch or Therion, per square centimeter | Policies naming Q4176 |
| Q4177 | On the list | FlowerAmnioflo, 0.1 cc | Policies naming Q4177 |
| Q4178 | On the list | FlowerAmniopatch, per square centimeter | Policies naming Q4178 |
| Q4179 | On the list | FlowerDerm, per square centimeter | Policies naming Q4179 |
| Q4180 | On the list | Revita, per square centimeter | Policies naming Q4180 |
| Q4181 | On the list | Amnio Wound, per square centimeter | Policies naming Q4181 |
| Q4183 | On the list | Surgigraft, per square centimeter | Policies naming Q4183 |
| Q4184 | On the list | Cellesta or Cellesta Duo, per square centimeter | Policies naming Q4184 |
| Q4185 | On the list | Cellesta flowable amnion (25 mg per cc); per 0.5 cc | Policies naming Q4185 |
| Q4188 | On the list | Amnioarmor, per square centimeter | Policies naming Q4188 |
| Q4189 | On the list | Artacent AC, 1 mg | Policies naming Q4189 |
| Q4190 | On the list | Artacent AC, per square centimeter | Policies naming Q4190 |
| Q4191 | On the list | Restorigin, per square centimeter | Policies naming Q4191 |
| Q4192 | On the list | Restorigin, 1 cc | Policies naming Q4192 |
| Q4193 | On the list | Coll-e-derm, per square centimeter | Policies naming Q4193 |
| Q4194 | On the list | Novachor, per square centimeter | Policies naming Q4194 |
| Q4195 | On the list | Puraply, per square centimeter | Policies naming Q4195 |
| Q4196 | On the list | PuraPly AM, per square centimeter | Policies naming Q4196 |
| Q4197 | On the list | PuraPly XT, per square centimeter | Policies naming Q4197 |
| Q4198 | On the list | Genesis amniotic membrane, per square centimeter | Policies naming Q4198 |
| Q4199 | On the list | Cygnus matrix, per square centimeter | Policies naming Q4199 |
| Q4200 | On the list | Skin TE, per square centimeter | Policies naming Q4200 |
| Q4201 | On the list | Matrion, per square centimeter | Policies naming Q4201 |
| Q4202 | On the list | Keroxx (2.5g/cc), 1cc | Policies naming Q4202 |
| Q4203 | On the list | Derma-gide, per square centimeter | Policies naming Q4203 |
| Q4204 | On the list | Xwrap, per square centimeter | Policies naming Q4204 |
| Q4205 | On the list | Membrane graft or Membrane wrap, per square centimeter | Policies naming Q4205 |
| Q4206 | On the list | Fluid flow or Fluid GF, 1 cc | Policies naming Q4206 |
| Q4208 | On the list | Novafix, per square cenitmeter | Policies naming Q4208 |
| Q4209 | On the list | Surgraft, per square centimeter | Policies naming Q4209 |
| Q4211 | On the list | Amnion bio or AxoBioMembrane, per square centimeter | Policies naming Q4211 |
| Q4212 | On the list | AlloGen, per cc | Policies naming Q4212 |
| Q4213 | On the list | Ascent, 0.5 mg | Policies naming Q4213 |
| Q4214 | On the list | Cellesta cord, per square centimeter | Policies naming Q4214 |
| Q4215 | On the list | Axolotl Ambient or Axolotl Cryo, 0.1 mg | Policies naming Q4215 |
| Q4216 | On the list | Artacent cord, per square centimeter | Policies naming Q4216 |
| Q4217 | On the list | Woundfix, BioWound, Woundfix Plus, BioWound Plus, Woundfix Xplus or BioWound Xplus, per square centimeter | Policies naming Q4217 |
| Q4218 | On the list | Surgicord, per square centimeter | Policies naming Q4218 |
| Q4219 | On the list | SurgiGRAFT-Dual, per square centimeter | Policies naming Q4219 |
| Q4220 | On the list | BellaCell HD or Surederm, per square centimeter | Policies naming Q4220 |
| Q4221 | On the list | Amniowrap2, per square centimeter | Policies naming Q4221 |
| Q4222 | On the list | Progenamatrix, per square centimeter | Policies naming Q4222 |
| Q4224 | On the list | Human health factor 10 amniotic patch (hhf10-p), per square centimeter | Policies naming Q4224 |
| Q4225 | On the list | Amniobind or DermaBind TL, per square centimeter | Policies naming Q4225 |
| Q4226 | On the list | MyOwn Skin, includes harvesting and preparation procedures, per square centimeter | Policies naming Q4226 |
| Q4227 | On the list | AmnioCore, per square centimeter | Policies naming Q4227 |
| Q4229 | On the list | Cogenex amniotic membrane, per square centimeter | Policies naming Q4229 |
| Q4230 | On the list | Cogenex flowable amnion, per 0.5 cc | Policies naming Q4230 |
| Q4232 | On the list | Corplex, per square centimeter | Policies naming Q4232 |
| Q4233 | On the list | SurFactor or NuDyn, per 0.5 cc | Policies naming Q4233 |
| Q4234 | On the list | XCellerate, per square centimeter | Policies naming Q4234 |
| Q4235 | On the list | Amniorepair or AltiPly, per square centimeter | Policies naming Q4235 |
| Q4236 | On the list | CarePATCH, per square centimeter | Policies naming Q4236 |
| Q4237 | On the list | Cryo-cord, per square centimeter | Policies naming Q4237 |
| Q4238 | On the list | Derm-Maxx, per square centimeter | Policies naming Q4238 |
| Q4239 | On the list | Amnio-Maxx or Amnio-Maxx Lite, per square centimeter | Policies naming Q4239 |
| Q4240 | On the list | CoreCyte, for topical use only, per 0.5 cc | Policies naming Q4240 |
| Q4241 | On the list | PolyCyte, for topical use only, per 0.5 cc | Policies naming Q4241 |
| Q4242 | On the list | AmnioCyte Plus, per 0.5 cc | Policies naming Q4242 |
| Q4245 | On the list | Amniotext, per cc | Policies naming Q4245 |
| Q4246 | On the list | Coretext or Protext, per cc | Policies naming Q4246 |
| Q4247 | On the list | Amniotext patch, per square centimeter | Policies naming Q4247 |
| Q4248 | On the list | Dermacyte Amniotic Membrane Allograft, per square centimeter | Policies naming Q4248 |
| Q4249 | On the list | Amniply, for topical use only, per square centimeter | Policies naming Q4249 |
| Q4250 | On the list | AmnioAMP-MP, per square centimeter | Policies naming Q4250 |
| Q4251 | On the list | Vim, per sq cm | Policies naming Q4251 |
| Q4252 | On the list | Vendaje, per sq cm | Policies naming Q4252 |
| Q4253 | On the list | Zenith Amniotic Membrane, per sq cm | Policies naming Q4253 |
| Q4254 | On the list | Novafix DL, per square centimeter | Policies naming Q4254 |
| Q4255 | On the list | REGUaRD, for topical use only, per square centimeter | Policies naming Q4255 |
| Q4256 | On the list | MLG-complete, per square centimeter | Policies naming Q4256 |
| Q4257 | On the list | Relese, per square centimeter | Policies naming Q4257 |
| Q4258 | On the list | Enverse, per square centimeter | Policies naming Q4258 |
| Q4259 | On the list | Celera dual layer or celera dual membrane, per square centimeter | Policies naming Q4259 |
| Q4260 | On the list | Signature Apatch, per square centimeter | Policies naming Q4260 |
| Q4261 | On the list | TAG, per square centimeter | Policies naming Q4261 |
| Q4262 | On the list | Dual Layer Impax Membrane, per square centimeter | Policies naming Q4262 |
| Q4263 | On the list | SurGraft TL, per square centimeter | Policies naming Q4263 |
| Q4264 | On the list | Cocoon membrane, per square centimeter | Policies naming Q4264 |
| Q4265 | On the list | NeoStim TL, per square centimeter | Policies naming Q4265 |
| Q4266 | On the list | NeoStim membrane, per square centimeter | Policies naming Q4266 |
| Q4267 | On the list | NeoStim DL, per square centimeter | Policies naming Q4267 |
| Q4268 | On the list | SurGraft FT, per square centimeter | Policies naming Q4268 |
| Q4269 | On the list | SurGraft XT, per square centimeter | Policies naming Q4269 |
| Q4270 | On the list | Complete SL, per square centimeter | Policies naming Q4270 |
| Q4271 | On the list | Complete FT, per square centimeter | Policies naming Q4271 |
| Q4272 | On the list | Esano A, per square centimeter | Policies naming Q4272 |
| Q4273 | On the list | Esano AAA, per square centimeter | Policies naming Q4273 |
| Q4274 | On the list | Esano AC, per square centimeter | Policies naming Q4274 |
| Q4275 | On the list | Esano ACA, per square centimeter | Policies naming Q4275 |
| Q4276 | On the list | Orion, per square centimeter | Policies naming Q4276 |
| Q4278 | On the list | EPIEFFECT, per square centimeter | Policies naming Q4278 |
| Q4279 | On the list | Vendaje AC, per square centimeter | Policies naming Q4279 |
| Q4280 | On the list | Xcell amnio matrix, per square centimeter | Policies naming Q4280 |
| Q4281 | On the list | Barrera SL or Barrera DL, per square centimeter | Policies naming Q4281 |
| Q4282 | On the list | Cygnus Dual, per square centimeter | Policies naming Q4282 |
| Q4284 | On the list | DermaBind SL, per square centimeter | Policies naming Q4284 |
| Q4285 | On the list | NuDYN DL or NuDYN DL mesh, per square centimeter | Policies naming Q4285 |
| Q4286 | On the list | NuDYN SL or NuDYN SLW, per square centimeter | Policies naming Q4286 |
| Q4287 | On the list | DermaBind DL, per square centimeter | Policies naming Q4287 |
| Q4288 | On the list | DermaBind CH, per square centimeter | Policies naming Q4288 |
| Q4289 | On the list | RevoShield + Amniotic Barrier, per square centimeter | Policies naming Q4289 |
| Q4290 | On the list | Membrane Wrap-Hydro, per square centimeter | Policies naming Q4290 |
| Q4291 | On the list | Lamellas XT, per square centimeter | Policies naming Q4291 |
| Q4292 | On the list | Lamellas, per square centimeter | Policies naming Q4292 |
| Q4293 | On the list | Acesso DL, per square centimeter | Policies naming Q4293 |
| Q4294 | On the list | Amnio Quad-Core, per square centimeter | Policies naming Q4294 |
| Q4295 | On the list | Amnio Tri-Core amniotic, per square centimeter | Policies naming Q4295 |
| Q4296 | On the list | Rebound Matrix, per square centimeter | Policies naming Q4296 |
| Q4297 | On the list | Emerge Matrix, per square centimeter | Policies naming Q4297 |
| Q4298 | On the list | AmnioCore Pro, per square centimeter | Policies naming Q4298 |
| Q4299 | On the list | AmniCore Pro+, per square centimeter | Policies naming Q4299 |
| Q4300 | On the list | Acesso TL, per square centimeter | Policies naming Q4300 |
| Q4301 | On the list | Activate Matrix, per square centimeter | Policies naming Q4301 |
| Q4302 | On the list | Complete ACA, per square centimeter | Policies naming Q4302 |
| Q4303 | On the list | Complete AA, per square centimeter | Policies naming Q4303 |
| Q4304 | On the list | Grafix Plus, per square centimeter | Policies naming Q4304 |
| Q4305 | On the list | American amnion AC tri-layer, per square centimeter | Policies naming Q4305 |
| Q4306 | On the list | American amnion AC, per square centimeter | Policies naming Q4306 |
| Q4307 | On the list | American amnion, per square centimeter | Policies naming Q4307 |
| Q4308 | On the list | Sanopellis, per square centimeter | Policies naming Q4308 |
| Q4309 | On the list | VIA Matrix, per square centimeter | Policies naming Q4309 |
| Q4310 | On the list | Procenta, per 200 mg | Policies naming Q4310 |
| Q4311 | On the list | Acesso, per square centimeter | Policies naming Q4311 |
| Q4312 | On the list | Acesso AC, per square centimeter | Policies naming Q4312 |
| Q4313 | On the list | DermaBind FM, per square centimeter | Policies naming Q4313 |
| Q4314 | On the list | Reeva FT, per square centimeter | Policies naming Q4314 |
| Q4315 | On the list | RegeneLink Amniotic Membrane allograft, per square centimeter | Policies naming Q4315 |
| Q4316 | On the list | AmchoPlast, per square centimeter | Policies naming Q4316 |
| Q4317 | On the list | VitoGraft, per square centimeter | Policies naming Q4317 |
| Q4318 | On the list | E-Graft, per square centimeter | Policies naming Q4318 |
| Q4319 | On the list | SanoGraft, per square centimeter | Policies naming Q4319 |
| Q4320 | On the list | PelloGraft, per square centimeter | Policies naming Q4320 |
| Q4321 | On the list | RenoGraft, per square centimeter | Policies naming Q4321 |
| Q4322 | On the list | CaregraFT, per square centimeter | Policies naming Q4322 |
| Q4323 | On the list | alloPLY, per square centimeter | Policies naming Q4323 |
| Q4324 | On the list | AmnioTX, per square centimeter | Policies naming Q4324 |
| Q4325 | On the list | ACApatch, per square centimeter | Policies naming Q4325 |
| Q4326 | On the list | WoundPlus, per square centimeter | Policies naming Q4326 |
| Q4327 | On the list | DuoAmnion, per square centimeter | Policies naming Q4327 |
| Q4328 | On the list | MOST, per square centimeter | Policies naming Q4328 |
| Q4329 | On the list | Singlay, per square centimeter | Policies naming Q4329 |
| Q4330 | On the list | TOTAL, per square centimeter | Policies naming Q4330 |
| Q4331 | On the list | Axolotl Graft, per square centimeter | Policies naming Q4331 |
| Q4332 | On the list | Axolotl DualGraft, per square centimeter | Policies naming Q4332 |
| Q4333 | On the list | ArdeoGraft, per square centimeter | Policies naming Q4333 |
| Q4336 | On the list | Artacent C, per square centimeter | Policies naming Q4336 |
| Q4337 | On the list | Artacent Trident, per square centimeter | Policies naming Q4337 |
| Q4338 | On the list | Artacent Velos, per square centimeter | Policies naming Q4338 |
| Q4339 | On the list | Artacent VeriClen, per square centimeter | Policies naming Q4339 |
| Q4340 | On the list | SimpliGraft, per square centimeter | Policies naming Q4340 |
| Q4341 | On the list | SimpliMax, per square centimeter | Policies naming Q4341 |
| Q4342 | On the list | TheraMend, per square centimeter | Policies naming Q4342 |
| Q4343 | On the list | Dermacyte AC matrix amniotic membrane allograft, per square centimeter | Policies naming Q4343 |
| Q4344 | On the list | Tri-membrane wrap, per square centimeter | Policies naming Q4344 |
| Q4345 | On the list | Matrix HD allograft dermis, per square centimeter | Policies naming Q4345 |
| Q4346 | On the list | Shelter DM Matrix, per square centimeter | Policies naming Q4346 |
| Q4347 | On the list | Rampart DL Matrix, per square centimeter | Policies naming Q4347 |
| Q4348 | On the list | Sentry SL Matrix, per square centimeter | Policies naming Q4348 |
| Q4349 | On the list | Mantle DL Matrix, per square centimeter | Policies naming Q4349 |
| Q4350 | On the list | Palisade DM Matrix, per square centimeter | Policies naming Q4350 |
| Q4351 | On the list | Enclose TL Matrix, per square centimeter | Policies naming Q4351 |
| Q4352 | On the list | Overlay SL Matrix, per square centimeter | Policies naming Q4352 |
| Q4353 | On the list | Xceed TL Matrix, per square centimeter | Policies naming Q4353 |
| Q4354 | On the list | PalinGen dual-layer membrane and dual-layer PalinGen X- membrane, per square centimeter | Policies naming Q4354 |
| Q4355 | On the list | Abiomend Xplus membrane and abiomend Xplus hydromembrane, per square centimeter | Policies naming Q4355 |
| Q4356 | On the list | Abiomend membrane and abiomend hydromembrane, per square centimeter | Policies naming Q4356 |
And 77 more in the original policy.
All Anthem Blue Cross Blue Shield of California policies · Anthem Blue Cross Blue Shield of California prior authorization CPT list