Blue Shield of California Promise Health Plan prior authorization G0682

Blue Shield of California Promise Health Plan prior authorization for G0682: 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; each additional 25 sq cm wound surface area, or part thereof (list separately in addition to code for primary procedure)

Code

G0682

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; each additional 25 sq cm wound surface area, or part thereof (list separately in addition to code for primary procedure)

Source

Medi-Cal Prior Authorization List, Pg 26 Original policy

Blue Shield of California Promise Health Plan prior authorization