Cigna prior authorization, page 43

Requirements

Read the care-management columns separately. Complete, PHS+, Preferred, and Basic Standard do not collapse into one Cigna answer. The long descriptor is blank because no AMA-licensed CPT file was available to copy.

Cigna precertification list

Cigna master precertification list

Cigna precertification

CPT code lookup

Prior authorization codes

Prior authorization codes
Code	Description	Source
Q4151*	Amnioband or guardian, per square centimeter	Master Precertification List For Health Care Providers, Pg 94 Original policy
Q4152*	Dermapure, per square centimeter	Master Precertification List For Health Care Providers, Pg 94 Original policy
Q4155*	Neoxflo or clarixflo, 1 mg	Master Precertification List For Health Care Providers, Pg 94 Original policy
Q4156*	Neox 100 or clarix 100, per square centimeter	Master Precertification List For Health Care Providers, Pg 94 Original policy
Q4158*	Kerecis omega3, per square centimeter	Master Precertification List For Health Care Providers, Pg 95 Original policy
Q4159*	Affinity, per square centimeter	Master Precertification List For Health Care Providers, Pg 95 Original policy
Q4160*	Nushield, per square centimeter	Master Precertification List For Health Care Providers, Pg 95 Original policy
Q4162*	Woundex flow, bioskin flow, 0.5 cc	Master Precertification List For Health Care Providers, Pg 95 Original policy
Q4163*	Woundex, bioskin, per square centimeter	Master Precertification List For Health Care Providers, Pg 95 Original policy
Q4164*	Helicoll, per square centimeter	Master Precertification List For Health Care Providers, Pg 95 Original policy
Q4166*	Cytal, per square centimeter	Master Precertification List For Health Care Providers, Pg 95 Original policy
Q4168*	Amnioband, 1 mg	Master Precertification List For Health Care Providers, Pg 95 Original policy
Q4170*	Cygnus, per square centimeter	Master Precertification List For Health Care Providers, Pg 95 Original policy
Q4173*	Palingen or palingen xplus, per square centimeter	Master Precertification List For Health Care Providers, Pg 95 Original policy
Q4174*	Palingen or promatrx, 0.36 mg per 0.25 cc	Master Precertification List For Health Care Providers, Pg 95 Original policy
Q4180*	Revita, per square centimeter	Master Precertification List For Health Care Providers, Pg 95 Original policy
Q4186*	Epifix, per square centimeter	Master Precertification List For Health Care Providers, Pg 95 Original policy
Q4187*	Epicord, per square centimeter	Master Precertification List For Health Care Providers, Pg 95 Original policy
Q4189*	Artacent ac, 1 mg	Master Precertification List For Health Care Providers, Pg 95 Original policy
Q4192*	Restorigin, 1 cc	Master Precertification List For Health Care Providers, Pg 95 Original policy
Q4193*	Coll-e-derm, per square centimeter	Master Precertification List For Health Care Providers, Pg 95 Original policy
Q4195*	Puraply, per square centimeter	Master Precertification List For Health Care Providers, Pg 95 Original policy
Q4196*	Puraply am, per square centimeter	Master Precertification List For Health Care Providers, Pg 95 Original policy
Q4215*	Axolotl ambient or axolotl cryo, 0.1 mg	Master Precertification List For Health Care Providers, Pg 95 Original policy
Q4222*	Progenamatrix, per square centimeter	Master Precertification List For Health Care Providers, Pg 95 Original policy
Q4227*	Amniocore, per square centimeter	Master Precertification List For Health Care Providers, Pg 95 Original policy
Q4229*	Cogenex amniotic membrane, per square centimeter	Master Precertification List For Health Care Providers, Pg 95 Original policy
Q4234*	Xcellerate, per square centimeter	Master Precertification List For Health Care Providers, Pg 95 Original policy
Q4235*	Amniorepair or altiply, per square centimeter	Master Precertification List For Health Care Providers, Pg 95 Original policy
Q4236*	Carepatch, per square centimeter	Master Precertification List For Health Care Providers, Pg 95 Original policy
Q4239*	Amnio-maxx or amnio-maxx lite, per square centimeter	Master Precertification List For Health Care Providers, Pg 95 Original policy
Q4243*	Amchomatrix, per square centimeter	Master Precertification List For Health Care Providers, Pg 95 Original policy
Q4246*	Coretext or protext, per cc	Master Precertification List For Health Care Providers, Pg 95 Original policy
Q4250*	Amnioamp-mp, per square centimeter	Master Precertification List For Health Care Providers, Pg 95 Original policy
Q4253*	Zenith amniotic membrane, per square centimeter	Master Precertification List For Health Care Providers, Pg 96 Original policy
Q4254*	Novafix dl, per square centimeter	Master Precertification List For Health Care Providers, Pg 96 Original policy
Q4262*	Dual layer impax membrane, per square centimeter	Master Precertification List For Health Care Providers, Pg 96 Original policy
Q4263*	Surgraft tl, per square centimeter	Master Precertification List For Health Care Providers, Pg 96 Original policy
Q4264*	Cocoon membrane, per square centimeter	Master Precertification List For Health Care Providers, Pg 96 Original policy
Q4265*	Neostim tl, per square centimeter	Master Precertification List For Health Care Providers, Pg 96 Original policy
Q4266*	Neostim membrane, per square centimeter	Master Precertification List For Health Care Providers, Pg 96 Original policy
Q4267*	Neostim dl, per square centimeter	Master Precertification List For Health Care Providers, Pg 96 Original policy
Q4268*	Surgraft ft, per square centimeter	Master Precertification List For Health Care Providers, Pg 96 Original policy
Q4269*	Surgraft xt, per square centimeter	Master Precertification List For Health Care Providers, Pg 96 Original policy
Q4270*	Complete sl, per square centimeter	Master Precertification List For Health Care Providers, Pg 96 Original policy
Q4271*	Complete ft, per square centimeter	Master Precertification List For Health Care Providers, Pg 96 Original policy
Q4272*	Esano a, per square centimeter	Master Precertification List For Health Care Providers, Pg 96 Original policy
Q4273*	Esano aaa, per square centimeter	Master Precertification List For Health Care Providers, Pg 96 Original policy
Q4274*	Esano ac, per square centimeter	Master Precertification List For Health Care Providers, Pg 96 Original policy
Q4275*	Esano aca, per square centimeter	Master Precertification List For Health Care Providers, Pg 96 Original policy

Removed codes

Cigna codes removed from the master precertification list

Sources

Disclaimer

The information provided on this page is for general informational purposes only and does not constitute billing, coding, or reimbursement advice. Nothing on this page should be relied upon as a substitute for clinician assessment, professional billing guidance, or as a definitive statement of any payor's billing requirements or policies.

Payor agreements, fee schedules, and billing policies vary and are subject to change. Before submitting any claims related to maternity care services, including claims affected by the 2027 CPT code revisions, please consult the applicable payor agreements, coverage policies, and billing guidelines to confirm current requirements for their specific payor contracts.

Substrate makes no representation or warranty regarding the accuracy, completeness, or timeliness of the payor-specific information presented here. Providers are solely responsible for ensuring that all claims are submitted in accordance with applicable payor requirements, and Substrate assumes no liability for claim denials, underpayments, or other adverse outcomes arising from reliance on this information.