Cigna prior authorization, page 44

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
Q4276*	Orion, per square centimeter	Master Precertification List For Health Care Providers, Pg 96 Original policy
Q4331*	Axolotl graft, per square centimeter	Master Precertification List For Health Care Providers, Pg 96 Original policy
Q4332*	Axolotl dualgraft, per square centimeter	Master Precertification List For Health Care Providers, Pg 96 Original policy
Q4345*	Matrix hd allograft dermis, per square centimeter	Master Precertification List For Health Care Providers, Pg 96 Original policy
Q4361*	Epiexpress, per square centimeter	Master Precertification List For Health Care Providers, Pg 96 Original policy
Q4383*	Axolotl graft ultra, per square centimeter	Master Precertification List For Health Care Providers, Pg 96 Original policy
Q4385*	Apollo ft, per square centimeter	Master Precertification List For Health Care Providers, Pg 96 Original policy
Q4386*	Acesso trifaca, per square centimeter	Master Precertification List For Health Care Providers, Pg 96 Original policy
Q4388*	Neothelium 4l, per square centimeter	Master Precertification List For Health Care Providers, Pg 96 Original policy
Q4389*	Neothelium 4l plus, per square centimeter	Master Precertification List For Health Care Providers, Pg 96 Original policy
Q4392*	Grafix duo, per square centimeter	Master Precertification List For Health Care Providers, Pg 96 Original policy
Q4393*	Surgraft ac, per square centimeter	Master Precertification List For Health Care Providers, Pg 96 Original policy
Q4394*	Surgraft aca, per square centimeter	Master Precertification List For Health Care Providers, Pg 96 Original policy
Q4395*	Acelagraft, per square centimeter	Master Precertification List For Health Care Providers, Pg 96 Original policy
Q4396*	Natalin, per square centimeter	Master Precertification List For Health Care Providers, Pg 97 Original policy
Q4397*	Summit aaa, per square centimeter	Master Precertification List For Health Care Providers, Pg 97 Original policy
Q4398*	Summit ac, per square centimeter	Master Precertification List For Health Care Providers, Pg 97 Original policy
Q4399*	Summit fx, per square centimeter	Master Precertification List For Health Care Providers, Pg 97 Original policy
Q4400*	Polygon3 membrane, per square centimeter	Master Precertification List For Health Care Providers, Pg 97 Original policy
Q4401*	Absolv3 membrane, per square centimeter	Master Precertification List For Health Care Providers, Pg 97 Original policy
Q4410*	Amchomatrixdl, per square centimeter	Master Precertification List For Health Care Providers, Pg 97 Original policy
Q4411*	Amniomatrixf4x, per square centimeter	Master Precertification List For Health Care Providers, Pg 97 Original policy
Q4413*	Cygnus solo, per square centimeter	Master Precertification List For Health Care Providers, Pg 97 Original policy
Q4420*	Nuform, per square centimeter	Master Precertification List For Health Care Providers, Pg 97 Original policy
Q4422*	A/c wrap, per square centimeter (add-on, list separately in addition to primary procedure)	Master Precertification List For Health Care Providers, Pg 97 Original policy
Q4423*	Biolab tri-membrane wrap flow, per square centimeter (add-on, list separately in addition to primary procedure)	Master Precertification List For Health Care Providers, Pg 97 Original policy
Q4424*	Revive ft, per square centimeter (add-on, list separately in addition to primary procedure)	Master Precertification List For Health Care Providers, Pg 97 Original policy
Q4436*	Renati ac membrane, per square centimeter	Master Precertification List For Health Care Providers, Pg 97 Original policy
Q4437*	Revival ac, per square centimeter (add-on, list separately in addition to primary procedure)	Master Precertification List For Health Care Providers, Pg 97 Original policy
Q4438*	Pretect, per square centimeter (add-on, list separately in addition to primary procedure)	Master Precertification List For Health Care Providers, Pg 97 Original policy
Q4440*	Curamatrix, per square centimeter (add-on, list separately in addition to primary procedure)	Master Precertification List For Health Care Providers, Pg 97 Original policy
Q5098	Injection, ustekinumab-srlf (imuldosa), biosimilar, 1 mg	Master Precertification List For Health Care Providers, Pg 97 Original policy
Q5099	Injection, ustekinumab-stba (steqeyma), biosimilar, 1 mg	Master Precertification List For Health Care Providers, Pg 97 Original policy
Q5100	Injection, ustekinumab-kfce (yesintek), biosimilar, 1 mg	Master Precertification List For Health Care Providers, Pg 97 Original policy
Q5103	Injection, infliximab-dyyb, biosimilar, (inflectra), 10 mg	Master Precertification List For Health Care Providers, Pg 97 Original policy
Q5104	Injection, infliximab-abda, biosimilar, (renflexis), 10 mg	Master Precertification List For Health Care Providers, Pg 97 Original policy
Q5105	Injection, epoetin alfa-epbx, biosimilar, (retacrit) (for esrd on dialysis), 100 units	Master Precertification List For Health Care Providers, Pg 97 Original policy
Q5106*	Injection, epoetin alfa-epbx, biosimilar, (retacrit) (for non-esrd use), 1000 units	Master Precertification List For Health Care Providers, Pg 97 Original policy
Q5107*	Injection, bevacizumab-awwb, biosimilar, (mvasi), 10 mg	Master Precertification List For Health Care Providers, Pg 97 Original policy
Q5108*	Injection, pegfilgrastim-jmdb (fulphila), biosimilar, 0.5 mg	Master Precertification List For Health Care Providers, Pg 97 Original policy
Q5111*	Injection, pegfilgrastim-cbqv (udenyca), biosimilar, 0.5 mg	Master Precertification List For Health Care Providers, Pg 97 Original policy
Q5112*	Injection, trastuzumab-dttb, biosimilar, (Ontruzant), 10 mg	Master Precertification List For Health Care Providers, Pg 97 Original policy
Q5113*	Injection, trastuzumab-pkrb, biosimilar, (Herzuma), 10 mg	Master Precertification List For Health Care Providers, Pg 97 Original policy
Q5114*	Injection, Trastuzumab-dkst, biosimilar, (Ogivri), 10 mg	Master Precertification List For Health Care Providers, Pg 97 Original policy
Q5115*	Injection, rituximab-abbs, biosimilar, (truxima), 10 mg	Master Precertification List For Health Care Providers, Pg 97 Original policy
Q5116*	Injection, trastuzumab-qyyp, biosimilar, (trazimera), 10 mg	Master Precertification List For Health Care Providers, Pg 98 Original policy
Q5117*	Injection, trastuzumab-anns, biosimilar, (kanjinti), 10 mg	Master Precertification List For Health Care Providers, Pg 98 Original policy
Q5118*	Injection, bevacizumab-bvzr, biosimilar, (Zirabev), 10 mg	Master Precertification List For Health Care Providers, Pg 98 Original policy
Q5119*	Injection, rituximab-pvvr, biosimilar, (ruxience), 10 mg	Master Precertification List For Health Care Providers, Pg 98 Original policy
Q5120*	Injection, pegfilgrastim-bmez (ziextenzo), biosimilar, 0.5 mg	Master Precertification List For Health Care Providers, Pg 98 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.

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