Bioengineered Skin and Soft Tissue Substitutes

Policy ID: S-33-045

Section: Surgery

Effective Date: November 01, 2019

Revised Date: March 18, 2024

Revision Effective Date: April 01, 2024

Last Reviewed: March 19, 2024

Applies To: Commercial and Medicaid Expansion

Description

Bio-engineered skin and soft tissue substitutes may be derived from human tissue (autologous or allogeneic), non-human tissue (xenographic), synthetic materials, or a composite of these materials. Bio-engineered skin and soft tissue substitutes are utilized in the treatment for breast reconstruction, healing of lower extremity ulcers and severe burns. Acellular dermal matrix (ADM) products are utilized in the repair of a variety of soft tissues.

Policy Application

For Date of Processing (DOP): All claims submitted for this policy will be processed according to the policy effective date and associated revision effective dates in effect on the date of processing, regardless of service date.

For Date of Service (DOS): All claims submitted for this policy will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

*See below to determine whether the policy rules apply to initial and adjustment claims based on date of processing (DOP) or Date of Service (DOS).

Criteria

Coverage is subject to the specific terms of the member's benefit plan.

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of processing, regardless of service date.

Breast Reconstructive Surgery

Breast reconstructive surgery using ONE of the following allogeneic ADM products may be considered medically necessary for any ONE of the following indications:

Product(s):

AlloDerm®; or
AlloMax™; or
AlloMend®; or
DermaMatrix™; or
DermACELL®; or
FlexHD®; or
GraftJacket®.

Indication(s):

When there is insufficient tissue expander or implant coverage by the pectoralis major muscle and additional coverage is required; or
When there is viable but compromised or thin post-mastectomy skin flaps that are at risk of dehiscence or necrosis; or
The infra-mammary fold and lateral mammary folds have been undermined during mastectomy and re-establishment of these landmarks is needed.

Breast reconstruction surgery using one of the allogeneic ADM products not meeting the criteria as indicated in this policy is considered not medically necessary.

Procedure Codes

15271

15272

15273

15274

15777

19357

19361

19364

19367

19368

19369

19380

Q4100

Q4107

Q4116

Q4128

Q4122

Treatment of Chronic, Noninfected, Full-thickness Diabetic Lower Extremity

Policy Application

Treatment of chronic, noninfected, full-thickness diabetic lower extremity ulcers using any ONE of the following tissue-engineered skin substitutes may be considered medically necessary:

AlloPatch®; or
Apligraf®; or
Dermagraft®; or
Integra® Dermal Regeneration Template; or
Oasis® Ultra Tri-Layer Matrix; or
Oasis Wound Matrix

Treatment of chronic, noninfected, full-thickness diabetic lower extremity ulcers not meeting the criteria as indicated in this policy will be considered not medically necessary.

Procedure Codes

15271

15272

15273

15274

15275

15276

15277

15278

Q4101

Q4102

Q4105

Q4106

Q4124

Q4128

Treatment of Chronic, Non-infected, Partial- or Full-thickness Lower Extremity Skin Ulcers due to Venous Insufficiency

Policy Application

Treatment of chronic, non-infected, partial- or full-thickness lower extremity skin ulcers due to venous insufficiency, which have not adequately responded following a one (1)-month period of conventional ulcer therapy, using any ONE of the following tissue-engineered skin substitutes may be considered medically necessary:

Apligraf; or
Oasis™ Wound Matrix; or
Oasis® Ultra Tri-Layer Matrix

Treatment of chronic, non-infected, partial- or full-thickness lower extremity skin ulcers due to venous insufficiency not meeting the criteria as indicated in this policy is considered not medically necessary.

Procedure Codes

15271

15272

15273

15274

15275

15276

15277

15278

Q4101

Q4102

Q4124

Treatment of Dystrophic Epidermolysis Bullosa

Policy Application

Treatment of dystrophic epidermolysis bullosa using the following tissue-engineered skin substitutes may be considered medically necessary for ALL of the following indications:

Product(s):

OrCel™.

Indication(s):

Treatment of mitten-hand deformity when standard wound therapy has failed; and
When provided in accordance with the Humanitarian Device Exemption (HDE) specifications of the Food and Drug Administration (FDA).

Treatment to dystrophic epidermolysis bullosa not meeting the criteria as indicated in this policy is considered not medically necessary.

Procedure Codes

15271

15272

15273

15274

15275

15276

15277

15278

Q4100

Treatment of Second- and Third-Degree Burns

Policy Application

Treatment of second- and third-degree burns using any ONE of the following tissue-engineered skin substitutes may be considered medically necessary.

Epicel®
- Treatment of deep dermal or full-thickness burns comprising a total body surface area greater than or equal to 30% when provided in accordance with the HDE specifications of the FDA; or
Integra Dermal Regeneration Template™; or
TransCyte™.

Treatment of second- and third-degree burns not meeting the criteria as indicated in this policy is considered not medically necessary.

Procedure Codes

15150

15151

15152

15155

15156

15157

15271

15272

15273

15274

15275

15276

15277

15278

Q4100

Q4105

Q4182

TheraSkin

Policy Application

TheraSkin® may be considered medically necessary for any ONE of the following indications:

In conjunction with standard therapeutic compression for the treatment of chronic, non-infected, partial or full-thickness skin ulcers due to venous insufficiency greater than one (1)-month duration and which have not adequately responded following a one (1)-month period of conventional ulcer therapy (e.g.., standard dressing changes, standard therapeutic compression, etc.); or
In conjunction with standard diabetic foot ulcer care for the treatment of full-thickness neuropathic diabetic foot ulcers greater than one (1)-month duration which have not adequately responded following at least four (4) weeks of conventional ulcer therapy (e.g., surgical debridement, complete off-loading and standard dressing changes, etc.) which can extend through the dermis, including tendon, muscle, joint capsule or bone exposure; or
Other uses supported by clinical results and clinical literature include pressure sores, skin cancer excision (e.g., Mohs Surgery), large surgical wounds (i.e., club release, etc.), radiation compromised wounds and necrotizing fasciitis.

TheraSkin® not meeting the criteria as indicated in this policy is considered not medically necessary.

Procedure Codes

15271

15272

15273

15274

15275

15276

15277

15278

Q4121

Other Skin and Soft Tissue Substitutes

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

ALLother skin and soft tissue substitutes not listed above are considered experimental/investigational and, therefore, non-covered, because the safety and/or effectiveness cannot be established by the available published peer-reviewed literature.

Procedure Codes

A2001

A2002

A2004

A2005

A2006

A2007

A2008

A2009

A2010

A2011

A2012

A2013

A2014

A2015

A2016

A2017

A2018

A2019

A2020

A2021

A2024

A2025

A2026

A4100

Q4100

Q4103

Q4104

Q4108

Q4110

Q4111

Q4112

Q4113

Q4114

Q4115

Q4117

Q4118

Q4123

Q4125

Q4126

Q4127

Q4128

Q4130

Q4134

Q4135

Q4136

Q4141

Q4142

Q4143

Q4146

Q4147

Q4149

Q4152

Q4158

Q4164

Q4166

Q4167

Q4175

Q4178

Q4179

Q4180

Q4181

Q4193

Q4195

Q4196

Q4197

Q4200

Q4202

Q4203

Q4204

Q4220

Q4222

Q4226

Q4238

Outpatient HCPCS (C Codes)

C5271

C5272

C5273

C5274

C5275

C5276

C5277

C5278

C9354

C9356

C9358

C9360

C9363

C9364

Diagnosis Codes

Covered Diagnosis Codes for Procedure Code Q4100

Q81.2

Covered Diagnosis Codes for Procedure CodeQ4121

L97 codes below must be billed with one of the following codes:I83.0-I83.029; I83.2-I83.229; I87.01-I87.013; I87.03-I87.033; I87.2; I87.31-I87.313; I87.33-I87.333; or E08.621; E09.621; E10.621; E11.621; E13.621

C43.0

C43.111

C43.112

C43.121

C43.122

C43.21

C43.22

C43.31

C43.39

C43.4

C43.51

C43.52

C43.59

C43.61

C43.62

C43.71

C43.72

C43.8

C44.00

C44.01

C44.02

C44.09

C44.102

C44.109

C44.112

C44.119

C44.122

C44.129

C44.192

C44.199

C44.202

C44.209

C44.212

C44.219

C44.222

C44.229

C44.292

C44.299

C44.311

C44.319

C44.321

C44.329

C44.391

C44.399

C44.40

C44.41

C44.42

C44.49

C44.500

C44.501

C44.509

C44.510

C44.511

C44.519

C44.520

C44.521

C44.529

C44.590

C44.591

C44.599

C44.602

C44.609

C44.612

C44.619

C44.622

C44.629

C44.692

C44.699

C44.702

C44.709

C44.712

C44.719

C44.722

C44.729

C44.792

C44.799

C44.80

C44.81

C44.82

C44.89

C79.2

D03.0

D03.111

D03.112

D03.122

D03.21

D03.22

D03.39

D03.4

D03.51

D03.52

D03.59

D03.61

D03.62

D03.71

D03.72

D03.8

D04.0

D04.111

D04.112

D04.121

D04.122

D04.21

D04.22

D04.39

D04.4

D04.5

D04.61

D04.62

D04.71

D04.72

D04.8

E08.621

E09.621

E10.621

E11.621

E13.621

I83.011

I83.012

I83.013

I83.014

I83.015

I83.018

I83.019

I83.021

I83.022

I83.023

I83.024

I83.025

I83.028

I83.029

I83.211

I83.212

I83.213

I83.214

I83.215

I83.218

I83.219

I83.221

I83.222

I83.223

I83.224

I83.225

I83.228

I83.229

I87.011

I87.012

I87.013

I87.031

I87.032

I87.033

I87.2

I87.311

I87.312

I87.313

I87.331

I87.332

I87.333

L89.010

L89.012

L89.013

L89.014

L89.020

L89.022

L89.023

L89.024

L89.110

L89.112

L89.113

L89.114

L89.120

L89.122

L89.123

L89.124

L89.130

L89.132

L89.133

L89.134

L89.140

L89.142

L89.143

L89.144

L89.150

L89.152

L89.153

L89.154

L89.210

L89.212

L89.213

L89.214

L89.220

L89.222

L89.223

L89.224

L89.310

L89.312

L89.313

L89.314

L89.320

L89.322

L89.323

L89.324

L89.42

L89.43

L89.44

L89.45

L89.500

L89.502

L89.503

L89.504

L89.510

L89.512

L89.513

L89.514

L89.520

L89.522

L89.523

L89.524

L89.600

L89.602

L89.603

L89.604

L89.610

L89.612

L89.613

L89.614

L89.620

L89.622

L89.623

L89.624

L89.810

L89.812

L89.813

L89.814

L89.890

L89.892

L89.893

L89.894

L97.111

L97.112

L97.113

L97.114

L97.115

L97.116

L97.118

L97.121

L97.122

L97.123

L97.124

L97.125

L97.126

L97.128

L97.211

L97.212

L97.213

L97.214

L97.215

L97.216

L97.218

L97.221

L97.222

L97.223

L97.224

L97.225

L97.226

L97.228

L97.311

L97.312

L97.313

L97.314

L97.315

L97.316

L97.318

L97.321

L97.322

L97.323

L97.324

L97.325

L97.326

L97.328

L97.411

L97.412

L97.413

L97.414

L97.415

L97.416

L97.418

L97.421

L97.422

L97.423

L97.424

L97.425

L97.426

L97.428

L97.511

L97.512

L97.513

L97.514

L97.515

L97.516

L97.518

L97.521

L97.522

L97.523

L97.524

L97.525

L97.526

L97.528

L97.811

L97.812

L97.813

L97.814

L97.815

L97.816

L97.818

L97.821

L97.822

L97.823

L97.824

L97.825

L97.826

L97.828

L97.911

L97.912

L97.913

L97.914

L97.915

L97.916

L97.918

L97.921

L97.922

L97.923

L97.924

L97.925

L97.926

L97.928

M72.6

T81.31XA

T81.31XD

T81.31XS

T81.33XA

Covered Diagnosis Codes for Procedure Code Q4116

C50.011

C50.012

C50.021

C50.022

C50.111

C50.112

C50.121

C50.122

C50.211

C50.212

C50.221

C50.222

C50.311

C50.312

C50.321

C50.322

C50.411

C50.412

C50.421

C50.422

C50.511

C50.512

C50.521

C50.522

C50.611

C50.612

C50.621

C50.622

C50.811

C50.812

C50.821

C50.822

C50.911

C50.912

C50.921

C50.922

C79.81

D05.01

D05.02

D05.11

D05.12

D05.81

D05.82

D05.91

D05.92

Z42.1

Z80.3

Z85.3

Z90.11

Z90.12

Z90.13

Covered Diagnosis Codes for Procedure Codes Q4101, Q4105, and Q4106

L97 codes below must be billed with one of the E codes from this section:

E08.621-E13.622

E08.621

E08.622

E09.621

E09.622

E10.621

E10.622

E11.621

E11.622

E13.621

E13.622

L97.111

L97.112

L97.113

L97.114

L97.115

L97.116

L97.118

L97.121

L97.122

L97.123

L97.124

L97.125

L97.126

L97.128

L97.201

L97.202

L97.203

L97.204

L97.211

L97.212

L97.213

L97.214

L97.215

L97.216

L97.218

L97.221

L97.222

L97.223

L97.224

L97.225

L97.226

L97.228

L97.301

L97.302

L97.303

L97.304

L97.311

L97.312

L97.313

L97.314

L97.315

L97.316

L97.318

L97.321

L97.322

L97.323

L97.324

L97.325

L97.326

L97.328

L97.401

L97.402

L97.403

L97.404

L97.411

L97.412

L97.413

L97.414

L97.415

L97.416

L97.418

L97.421

L97.422

L97.423

L97.424

L97.425

L97.426

L97.428

L97.501

L97.502

L97.503

L97.504

L97.511

L97.512

L97.513

L97.514

L97.515

L97.516

L97.518

L97.521

L97.522

L97.523

L97.524

L97.525

L97.526

L97.528

L97.801

L97.802

L97.803

L97.804

L97.811

L97.812

L97.813

L97.814

L97.815

L97.816

L97.818

L97.821

L97.822

L97.823

L97.824

L97.825

L97.826

L97.828

L97.901

L97.902

L97.903

L97.904

L97.911

L97.912

L97.913

L97.914

L97.915

L97.916

L97.918

L97.921

L97.922

L97.923

L97.924

L97.925

L97.926

L97.928

Covered Diagnosis Codes for Procedure Codes Q4101, Q4102 and Q4124

L97 codes below must be billed with one of the following codes: I83.0-I83.029; I83.2-I83.229; I87.01-I87.013; I87.03-I87.033; I87.2; I87.31-I87.313; I87.33-I87.333

I83.011

I83.012

I83.013

I83.014

I83.015

I83.018

I83.019

I83.021

I83.022

I83.023

I83.024

I83.025

I83.028

I83.029

I83.211

I83.212

I83.213

I83.214

I83.215

I83.218

I83.219

I83.221

I83.222

I83.223

I83.224

I83.225

I83.228

I83.229

I87.011

I87.012

I87.013

I87.031

I87.032

I87.033

I87.2

I87.311

I87.312

I87.313

I87.331

I87.332

I87.333

L97.111

L97.112

L97.113

L97.114

L97.115

L97.116

L97.118

L97.121

L97.122

L97.123

L97.124

L97.125

L97.126

L97.128

L97.211

L97.212

L97.213

L97.214

L97.215

L97.216

L97.218

L97.221

L97.222

L97.223

L97.224

L97.225

L97.226

L97.228

L97.311

L97.312

L97.313

L97.314

L97.315

L97.316

L97.318

L97.321

L97.322

L97.323

L97.324

L97.325

L97.326

L97.328

L97.411

L97.412

L97.413

L97.414

L97.415

L97.416

L97.418

L97.421

L97.422

L97.423

L97.424

L97.425

L97.426

L97.428

L97.511

L97.512

L97.513

L97.514

L97.515

L97.516

L97.518

L97.521

L97.522

L97.523

L97.524

L97.525

L97.526

L97.528

L97.811

L97.812

L97.813

L97.814

L97.815

L97.816

L97.818

L97.821

L97.822

L97.823

L97.824

L97.825

L97.826

L97.828

L97.911

L97.912

L97.913

L97.914

L97.915

L97.916

L97.918

L97.919

L97.921

L97.922

L97.923

L97.924

L97.925

L97.926

L97.928

L97.929

Covered Diagnosis Codes for Procedure Codes Q4105 and Q4182

T20.20XA

T20.20XD

T20.20XS

T20.211A

T20.211D

T20.211S

T20.212A

T20.212D

T20.212S

T20.22XA

T20.22XD

T20.22XS

T20.23XA

T20.23XD

T20.23XS

T20.24XA

T20.24XD

T20.24XS

T20.25XA

T20.25XD

T20.25XS

T20.26XA

T20.26XD

T20.26XS

T20.27XA

T20.27XD

T20.27XS

T20.29XA

T20.29XD

T20.29XS

T20.30XA

T20.30XD

T20.30XS

T20.311A

T20.311D

T20.311S

T20.312A

T20.312D

T20.312S

T20.32XA

T20.32XD

T20.32XS

T20.33XA

T20.33XD

T20.33XS

T20.34XA

T20.34XD

T20.34XS

T20.35XA

T20.35XD

T20.35XS

T20.36XA

T20.36XD

T20.36XS

T20.37XA

T20.37XD

T20.37XS

T20.39XA

T20.39XD

T20.39XS

T20.60XA

T20.60XD

T20.60XS

T20.611A

T20.611D

T20.611S

T20.612A

T20.612D

T20.612S

T20.62XA

T20.62XD

T20.62XS

T20.63XA

T20.63XD

T20.63XS

T20.64XA

T20.64XD

T20.64XS

T20.65XA

T20.65XD

T20.65XS

T20.66XA

T20.66XD

T20.66XS

T20.67XA

T20.67XD

T20.67XS

T20.69XA

T20.69XD

T20.69XS

T20.70XA

T20.70XD

T20.70XS

T20.711A

T20.711D

T20.711S

T20.712A

T20.712D

T20.712S

T20.72XA

T20.72XD

T20.72XS

T20.73XA

T20.73XD

T20.73XS

T20.74XA

T20.74XD

T20.74XS

T20.75XA

T20.75XD

T20.75XS

T20.76XA

T20.76XD

T20.76XS

T20.77XA

T20.77XD

T20.77XS

T20.79XA

T20.79XD

T20.79XS

T21.21XA

T21.21XD

T21.21XS

T21.22XA

T21.22XD

T21.22XS

T21.23XA

T21.23XD

T21.23XS

T21.24XA

T21.24XD

T21.24XS

T21.25XA

T21.25XD

T21.25XS

T21.26XA

T21.26XD

T21.26XS

T21.27XA

T21.27XD

T21.27XS

T21.29XA

T21.29XD

T21.29XS

T21.31XA

T21.31XD

T21.31XS

T21.32XA

T21.32XD

T21.32XS

T21.33XA

T21.33XD

T21.33XS

T21.34XA

T21.34XD

T21.34XS

T21.35XA

T21.35XD

T21.35XS

T21.36XA

T21.36XD

T21.36XS

T21.37XA

T21.37XD

T21.37XS

T21.39XA

T21.39XD

T21.39XS

T21.61XA

T21.61XD

T21.61XS

T21.62XA

T21.62XD

T21.62XS

T21.63XA

T21.63XD

T21.63XS

T21.64XA

T21.64XD

T21.64XS

T21.65XA

T21.65XD

T21.65XS

T21.66XA

T21.66XD

T21.66XS

T21.67XA

T21.67XD

T21.67XS

T21.69XA

T21.69XD

T21.69XS

T21.71XA

T21.71XD

T21.71XS

T21.72XA

T21.72XD

T21.72XS

T21.73XA

T21.73XD

T21.73XS

T21.74XA

T21.74XD

T21.74XS

T21.75XA

T21.75XD

T21.75XS

T21.76XA

T21.76XD

T21.76XS

T21.77XA

T21.77XD

T21.77XS

T21.79XA

T21.79XD

T21.79XS

T22.20XA

T22.20XD

T22.20XS

T22.211A

T22.211D

T22.211S

T22.212A

T22.212D

T22.212S

T22.221A

T22.221D

T22.221S

T22.222A

T22.222D

T22.222S

T22.231A

T22.231D

T22.231S

T22.232A

T22.232D

T22.232S

T22.241A

T22.241D

T22.241S

T22.242A

T22.242D

T22.242S

T22.251A

T22.251D

T22.251S

T22.252A

T22.252D

T22.252S

T22.261A

T22.261D

T22.261S

T22.262A

T22.262D

T22.262S

T22.291A

T22.291D

T22.291S

T22.292A

T22.292D

T22.292S

T22.30XA

T22.30XD

T22.30XS

T22.311A

T22.311D

T22.311S

T22.312A

T22.312D

T22.312S

T22.321A

T22.321D

T22.321S

T22.322A

T22.322D

T22.322S

T22.331A

T22.331D

T22.331S

T22.332A

T22.332D

T22.332S

T22.341A

T22.341D

T22.341S

T22.342A

T22.342D

T22.342S

T22.351A

T22.351D

T22.351S

T22.352A

T22.352D

T22.352S

T22.361A

T22.361D

T22.361S

T22.362A

T22.362D

T22.362S

T22.391A

T22.391D

T22.391S

T22.392A

T22.392D

T22.392S

T22.60XA

T22.60XD

T22.60XS

T22.611A

T22.611D

T22.611S

T22.612A

T22.612D

T22.612S

T22.621A

T22.621D

T22.621S

T22.622A

T22.622D

T22.622S

T22.631A

T22.631D

T22.631S

T22.632A

T22.632D

T22.632S

T22.641A

T22.641D

T22.641S

T22.642A

T22.642D

T22.642S

T22.651A

T22.651D

T22.651S

T22.652A

T22.652D

T22.652S

T22.661A

T22.661D

T22.661S

T22.662A

T22.662D

T22.662S

T22.691A

T22.691D

T22.691S

T22.692A

T22.692D

T22.692S

T22.70XA

T22.70XD

T22.70XS

T22.711A

T22.711D

T22.711S

T22.712A

T22.712D

T22.712S

T22.721A

T22.721D

T22.721S

T22.722A

T22.722D

T22.722S

T22.731A

T22.731D

T22.731S

T22.732A

T22.732D

T22.732S

T22.741A

T22.741D

T22.741S

T22.742A

T22.742D

T22.742S

T22.751A

T22.751D

T22.751S

T22.752A

T22.752D

T22.752S

T22.761A

T22.761D

T22.761S

T22.762A

T22.762D

T22.762S

T22.791A

T22.791D

T22.791S

T22.792A

T22.792D

T22.792S

T23.201A

T23.201D

T23.201S

T23.202A

T23.202D

T23.202S

T23.211A

T23.211D

T23.211S

T23.212A

T23.212D

T23.212S

T23.221A

T23.221D

T23.221S

T23.222A

T23.222D

T23.222S

T23.231A

T23.231D

T23.231S

T23.232A

T23.232D

T23.232S

T23.241A

T23.241D

T23.241S

T23.242A

T23.242D

T23.242S

T23.251A

T23.251D

T23.251S

T23.252A

T23.252D

T23.252S

T23.261A

T23.261D

T23.261S

T23.262A

T23.262D

T23.262S

T23.271A

T23.271D

T23.271S

T23.272A

T23.272D

T23.272S

T23.291A

T23.291D

T23.291S

T23.292A

T23.292D

T23.292S

T23.301A

T23.301D

T23.301S

T23.302A

T23.302D

T23.302S

T23.311A

T23.311D

T23.311S

T23.312A

T23.312D

T23.312S

T23.321A

T23.321D

T23.321S

T23.322A

T23.322D

T23.322S

T23.331A

T23.331D

T23.331S

T23.332A

T23.332D

T23.332S

T23.341A

T23.341D

T23.341S

T23.342A

T23.342D

T23.342S

T23.351A

T23.351D

T23.351S

T23.352A

T23.352D

T23.352S

T23.361A

T23.361D

T23.361S

T23.362A

T23.362D

T23.362S

T23.371A

T23.371D

T23.371S

T23.372A

T23.372D

T23.372S

T23.391A

T23.391D

T23.391S

T23.392A

T23.392D

T23.392S

T23.601A

T23.601D

T23.601S

T23.602A

T23.602D

T23.602S

T23.611A

T23.611D

T23.611S

T23.612A

T23.612D

T23.612S

T23.621A

T23.621D

T23.621S

T23.622A

T23.622D

T23.622S

T23.631A

T23.631D

T23.631S

T23.632A

T23.632D

T23.632S

T23.641A

T23.641D

T23.641S

T23.642A

T23.642D

T23.642S

T23.651A

T23.651D

T23.651S

T23.652A

T23.652D

T23.652S

T23.661A

T23.661D

T23.661S

T23.662A

T23.662D

T23.662S

T23.671A

T23.671D

T23.671S

T23.672A

T23.672D

T23.672S

T23.691A

T23.691D

T23.691S

T23.692A

T23.692D

T23.692S

T23.701A

T23.701D

T23.701S

T23.702A

T23.702D

T23.702S

T23.711A

T23.711D

T23.711S

T23.712A

T23.712D

T23.712S

T23.721A

T23.721D

T23.721S

T23.722A

T23.722D

T23.722S

T23.731A

T23.731D

T23.731S

T23.732A

T23.732D

T23.732S

T23.741A

T23.741D

T23.741S

T23.742A

T23.742D

T23.742S

T23.751A

T23.751D

T23.751S

T23.752A

T23.752D

T23.752S

T23.761A

T23.761D

T23.761S

T23.762A

T23.762D

T23.762S

T23.771A

T23.771D

T23.771S

T23.772A

T23.772D

T23.772S

T23.791A

T23.791D

T23.791S

T23.792A

T23.792D

T23.792S

T24.201A

T24.201D

T24.201S

T24.202A

T24.202D

T24.202S

T24.211A

T24.211D

T24.211S

T24.212A

T24.212D

T24.212S

T24.221A

T24.221D

T24.221S

T24.222A

T24.222D

T24.222S

T24.231A

T24.231D

T24.231S

T24.232A

T24.232D

T24.232S

T24.291A

T24.291D

T24.291S

T24.292A

T24.292D

T24.292S

T24.301A

T24.301D

T24.301S

T24.302A

T24.302D

T24.302S

T24.311A

T24.311D

T24.311S

T24.312A

T24.312D

T24.312S

T24.321A

T24.321D

T24.321S

T24.322A

T24.322D

T24.322S

T24.331A

T24.331D

T24.331S

T24.332A

T24.332D

T24.332S

T24.391A

T24.391D

T24.391S

T24.392A

T24.392D

T24.392S

T24.601A

T24.601D

T24.601S

T24.602A

T24.602D

T24.602S

T24.611A

T24.611D

T24.611S

T24.612A

T24.612D

T24.612S

T24.621A

T24.621D

T24.621S

T24.622A

T24.622D

T24.622S

T24.631A

T24.631D

T24.631S

T24.632A

T24.632D

T24.632S

T24.691A

T24.691D

T24.691S

T24.692A

T24.692D

T24.692S

T24.701A

T24.701D

T24.701S

T24.702A

T24.702D

T24.702S

T24.711A

T24.711D

T24.711S

T24.712A

T24.712D

T24.712S

T24.721A

T24.721D

T24.721S

T24.722A

T24.722D

T24.722S

T24.731A

T24.731D

T24.731S

T24.732A

T24.732D

T24.732S

T24.791A

T24.791D

T24.791S

T24.792A

T24.792D

T24.792S

T25.211A

T25.211D

T25.211S

T25.212A

T25.212D

T25.212S

T25.221A

T25.221D

T25.221S

T25.222A

T25.222D

T25.222S

T25.231A

T25.231D

T25.231S

T25.232A

T25.232D

T25.232S

T25.291A

T25.291D

T25.291S

T25.292A

T25.292D

T25.292S

T25.311A

T25.311D

T25.311S

T25.312A

T25.312D

T25.312S

T25.321A

T25.321D

T25.321S

T25.322A

T25.322D

T25.322S

T25.331A

T25.331D

T25.331S

T25.332A

T25.332D

T25.332S

T25.391A

T25.391D

T25.391S

T25.392A

T25.392D

T25.392S

T25.611A

T25.611D

T25.611S

T25.612A

T25.612D

T25.612S

T25.621A

T25.621D

T25.621S

T25.622A

T25.622D

T25.622S

T25.631A

T25.631D

T25.631S

T25.632A

T25.632D

T25.632S

T25.691A

T25.691D

T25.691S

T25.692A

T25.692D

T25.692S

T25.711A

T25.711D

T25.711S

T25.712A

T25.712D

T25.712S

T25.721A

T25.721D

T25.721S

T25.722A

T25.722D

T25.722S

T25.731A

T25.731D

T25.731S

T25.732A

T25.732D

T25.732S

T25.791A

T25.791D

T25.791S

T25.792A

T25.792D

T25.792S

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Medical Review 6-15-2020 - Coding HCPCS Updates - Effective July 01, 2020

Internal Medical Policy Committee 9-22-2020 Coding update:

Added procedure codes Q4102 and Q4124 under section involving 'Treatment of chronic, noninfected, full-thickness diabetic lower extremity ulcers'

Added procedure code Q4124 under section regarding 'Treatment of chronic, non-infected, partial- or full-thickness lower extremity skin ulcers due to venous insufficiency'

Removed procedure code Q4124 from section regarding: ALL other skin and soft tissue substitutes

Internal Medical Policy Committee 1-19-2021 Coding update

Removed Procedure code 19366

Internal Medical Policy Committee 11-23-2021 Coding update-

Added Procedure codes A2001; A2002; A2003; A2004; A2005; A2006; A2007; A2008; A2009; and A2010

Internal Medical Policy Committee 3-23-2022 Coding update- Effective April 01, 2022

Added Procedure codes A2011; A2012; A2013; and A4100; and
Removed BIO-connect and Procedure code A2003

Internal Medical Policy Committee 7-21-2022 Revision

Removed Product names

Internal Medical Policy Committee 9-28-2022 Coding update - Effective October 01, 2022

Added Procedure codes A2014; A2015; A2016; A2017; and A2018.

Internal Medical Policy Committee 11-29-2022 Coding update - Effective January 01, 2023

Removed procedure code C1849

Internal Medical Policy Committee 3-23-2023 Coding update - Effective April 01, 2023

Added procedure codes A2019; A2020; and A2021.

Internal Medical Policy Committee 11-15-2023 Coding update - Effective October 01, 2023

Added procedure codes A2024; A2025; Q4178; Q4180; Q4181; and Q4204.

Internal Medical Policy Committee 1-16-2024 Coding update

Added procedure codes Q4178; Q4180; Q4181; and Q4204.

Internal Medical Policy Committee 3-19-2024 Coding update - Effective April 01, 2024

Added procedure code A2026; and
Removed procedure code Q4172; and
Added Policy Application

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.

Policy ID: S-33-044

Section: Surgery

Effective Date: November 01, 2019

Revised Date: September 28, 2023

Revision Effective Date: October 01, 2023

Last Reviewed: November 15, 2023

Archived Date: March 31, 2024

Applies To: Commercial and Medicaid Expansion

Description

Criteria

Breast reconstructive surgery using ONE of the following allogeneic ADM products may be considered medically necessary for any ONE of the following indications:

Product(s):

AlloDerm®; or
AlloMax™; or
AlloMend®; or
DermaMatrix™; or
DermACELL®; or
FlexHD®; or
GraftJacket®.

Indication(s):

When there is insufficient tissue expander or implant coverage by the pectoralis major muscle and additional coverage is required; or
When there is viable but compromised or thin post-mastectomy skin flaps that are at risk of dehiscence or necrosis; or
The infra-mammary fold and lateral mammary folds have been undermined during mastectomy and re-establishment of these landmarks is needed.

Breast reconstruction surgery using one of the allogeneic ADM products not meeting the criteria as indicated in this policy is considered not medically necessary.

Procedure Codes

15271

15272

15273

15274

15777

19357

19361

19364

19367

19368

19369

19380

Q4100

Q4107

Q4116

Q4128

Q4122

Treatment of chronic, noninfected, full-thickness diabetic lower extremity ulcers using any ONE of the following tissue-engineered skin substitutes may be considered medically necessary:

AlloPatch®; or
Apligraf®; or
Dermagraft®; or
Integra® Dermal Regeneration Template; or
Oasis® Ultra Tri-Layer Matrix; or
Oasis Wound Matrix

Treatment of chronic, noninfected, full-thickness diabetic lower extremity ulcers not meeting the criteria as indicated in this policy will be considered not medically necessary.

Procedure Codes

15271

15272

15273

15274

15275

15276

15277

15278

Q4101

Q4102

Q4105

Q4106

Q4124

Q4128

Apligraf; or
Oasis™ Wound Matrix; or
Oasis® Ultra Tri-Layer Matrix

Procedure Codes

15271

15272

15273

15274

15275

15276

15277

15278

Q4101

Q4102

Q4124

Treatment of dystrophic epidermolysis bullosa using the following tissue-engineered skin substitutes may be considered medically necessary for ALL of the following indications:

Product(s):

OrCel™.

Indication(s):

Treatment of mitten-hand deformity when standard wound therapy has failed; and
When provided in accordance with the Humanitarian Device Exemption (HDE) specifications of the Food and Drug Administration (FDA).

Treatment to dystrophic epidermolysis bullosa not meeting the criteria as indicated in this policy is considered not medically necessary.

Procedure Codes

15271

15272

15273

15274

15275

15276

15277

15278

Q4100

Treatment of second- and third-degree burns using any ONE of the following tissue-engineered skin substitutes may be considered medically necessary.

Epicel®
- Treatment of deep dermal or full-thickness burns comprising a total body surface area greater than or equal to 30% when provided in accordance with the HDE specifications of the FDA; or
Integra Dermal Regeneration Template™; or
TransCyte™.

Treatment of second- and third-degree burns not meeting the criteria as indicated in this policy is considered not medically necessary.

Procedure Codes

15150

15151

15152

15155

15156

15157

15271

15272

15273

15274

15275

15276

15277

15278

Q4100

Q4105

Q4182

TheraSkin® may be considered medically necessary for any ONE of the following indications:

In conjunction with standard therapeutic compression for the treatment of chronic, non-infected, partial or full-thickness skin ulcers due to venous insufficiency greater than one (1)-month duration and which have not adequately responded following a one (1)-month period of conventional ulcer therapy (e.g.., standard dressing changes, standard therapeutic compression, etc.); or
In conjunction with standard diabetic foot ulcer care for the treatment of full-thickness neuropathic diabetic foot ulcers greater than one (1)-month duration which have not adequately responded following at least four (4) weeks of conventional ulcer therapy (e.g., surgical debridement, complete off-loading and standard dressing changes, etc.) which can extend through the dermis, including tendon, muscle, joint capsule or bone exposure; or
Other uses supported by clinical results and clinical literature include pressure sores, skin cancer excision (e.g., Mohs Surgery), large surgical wounds (i.e., club release, etc.), radiation compromised wounds and necrotizing fasciitis.

TheraSkin® not meeting the criteria as indicated in this policy is considered not medically necessary.

Procedure Codes

15271

15272

15273

15274

15275

15276

15277

15278

Q4121

ALL other skin and soft tissue substitutes not listed above are considered experimental/investigational and, therefore, non-covered, because the safety and/or effectiveness cannot be established by the available published peer-reviewed literature.

Procedure Codes

A2001

A2002

A2004

A2005

A2006

A2007

A2008

A2009

A2010

A2011

A2012

A2013

A2014

A2015

A2016

A2017

A2018

A2019

A2020

A2021

A2024

A2025

A4100

Q4100

Q4103

Q4104

Q4108

Q4110

Q4111

Q4112

Q4113

Q4114

Q4115

Q4117

Q4118

Q4123

Q4125

Q4126

Q4127

Q4128

Q4130

Q4134

Q4135

Q4136

Q4141

Q4142

Q4143

Q4146

Q4147

Q4149

Q4152

Q4158

Q4164

Q4166

Q4167

Q4172

Q4175

Q4178

Q4179

Q4180

Q4181

Q4193

Q4195

Q4196

Q4197

Q4200

Q4202

Q4203

Q4204

Q4220

Q4222

Q4226

Q4238

Outpatient HCPCS (C Codes)

C5271

C5272

C5273

C5274

C5275

C5276

C5277

C5278

C9354

C9356

C9358

C9360

C9363

C9364

Diagnosis Codes

Covered Diagnosis Codes for Procedure Code Q4100

Q81.2

Covered Diagnosis Codes for Procedure CodeQ4121

L97 codes below must be billed with one of the following codes:I83.0-I83.029, I83.2-I83.229, I87.01-I87.013, I87.03-I87.033, I87.2, I87.31-I87.313, I87.33-I87.333 or E08.621, E09.621, E10.621, E11.621, E13.621

C43.0

C43.111

C43.112

C43.121

C43.122

C43.21

C43.22

C43.31

C43.39

C43.4

C43.51

C43.52

C43.59

C43.61

C43.62

C43.71

C43.72

C43.8

C44.00

C44.01

C44.02

C44.09

C44.102

C44.109

C44.112

C44.119

C44.122

C44.129

C44.192

C44.199

C44.202

C44.209

C44.212

C44.219

C44.222

C44.229

C44.292

C44.299

C44.311

C44.319

C44.321

C44.329

C44.391

C44.399

C44.40

C44.41

C44.42

C44.49

C44.500

C44.501

C44.509

C44.510

C44.511

C44.519

C44.520

C44.521

C44.529

C44.590

C44.591

C44.599

C44.602

C44.609

C44.612

C44.619

C44.622

C44.629

C44.692

C44.699

C44.702

C44.709

C44.712

C44.719

C44.722

C44.729

C44.792

C44.799

C44.80

C44.81

C44.82

C44.89

C79.2

D03.0

D03.111

D03.112

D03.122

D03.21

D03.22

D03.39

D03.4

D03.51

D03.52

D03.59

D03.61

D03.62

D03.71

D03.72

D03.8

D04.0

D04.111

D04.112

D04.121

D04.122

D04.21

D04.22

D04.39

D04.4

D04.5

D04.61

D04.62

D04.71

D04.72

D04.8

E08.621

E09.621

E10.621

E11.621

E13.621

I83.011

I83.012

I83.013

I83.014

I83.015

I83.018

I83.019

I83.021

I83.022

I83.023

I83.024

I83.025

I83.028

I83.029

I83.211

I83.212

I83.213

I83.214

I83.215

I83.218

I83.219

I83.221

I83.222

I83.223

I83.224

I83.225

I83.228

I83.229

I87.011

I87.012

I87.013

I87.031

I87.032

I87.033

I87.2

I87.311

I87.312

I87.313

I87.331

I87.332

I87.333

L89.010

L89.012

L89.013

L89.014

L89.020

L89.022

L89.023

L89.024

L89.110

L89.112

L89.113

L89.114

L89.120

L89.122

L89.123

L89.124

L89.130

L89.132

L89.133

L89.134

L89.140

L89.142

L89.143

L89.144

L89.150

L89.152

L89.153

L89.154

L89.210

L89.212

L89.213

L89.214

L89.220

L89.222

L89.223

L89.224

L89.310

L89.312

L89.313

L89.314

L89.320

L89.322

L89.323

L89.324

L89.42

L89.43

L89.44

L89.45

L89.500

L89.502

L89.503

L89.504

L89.510

L89.512

L89.513

L89.514

L89.520

L89.522

L89.523

L89.524

L89.600

L89.602

L89.603

L89.604

L89.610

L89.612

L89.613

L89.614

L89.620

L89.622

L89.623

L89.624

L89.810

L89.812

L89.813

L89.814

L89.890

L89.892

L89.893

L89.894

L97.111

L97.112

L97.113

L97.114

L97.115

L97.116

L97.118

L97.121

L97.122

L97.123

L97.124

L97.125

L97.126

L97.128

L97.211

L97.212

L97.213

L97.214

L97.215

L97.216

L97.218

L97.221

L97.222

L97.223

L97.224

L97.225

L97.226

L97.228

L97.311

L97.312

L97.313

L97.314

L97.315

L97.316

L97.318

L97.321

L97.322

L97.323

L97.324

L97.325

L97.326

L97.328

L97.411

L97.412

L97.413

L97.414

L97.415

L97.416

L97.418

L97.421

L97.422

L97.423

L97.424

L97.425

L97.426

L97.428

L97.511

L97.512

L97.513

L97.514

L97.515

L97.516

L97.518

L97.521

L97.522

L97.523

L97.524

L97.525

L97.526

L97.528

L97.811

L97.812

L97.813

L97.814

L97.815

L97.816

L97.818

L97.821

L97.822

L97.823

L97.824

L97.825

L97.826

L97.828

L97.911

L97.912

L97.913

L97.914

L97.915

L97.916

L97.918

L97.921

L97.922

L97.923

L97.924

L97.925

L97.926

L97.928

M72.6

T81.31XA

T81.31XD

T81.31XS

T81.33XA

Covered Diagnosis Codes for Procedure Code Q4116

C50.011

C50.012

C50.021

C50.022

C50.111

C50.112

C50.121

C50.122

C50.211

C50.212

C50.221

C50.222

C50.311

C50.312

C50.321

C50.322

C50.411

C50.412

C50.421

C50.422

C50.511

C50.512

C50.521

C50.522

C50.611

C50.612

C50.621

C50.622

C50.811

C50.812

C50.821

C50.822

C50.911

C50.912

C50.921

C50.922

C79.81

D05.01

D05.02

D05.11

D05.12

D05.81

D05.82

D05.91

D05.92

Z42.1

Z80.3

Z85.3

Z90.11

Z90.12

Z90.13

Covered Diagnosis Codes for Procedure Codes Q4101, Q4105, and Q4106

L97 codes below must be billed with one of the E codes from this section: E08.621-E13.622

E08.621

E08.622

E09.621

E09.622

E10.621

E10.622

E11.621

E11.622

E13.621

E13.622

L97.111

L97.112

L97.113

L97.114

L97.115

L97.116

L97.118

L97.121

L97.122

L97.123

L97.124

L97.125

L97.126

L97.128

L97.201

L97.202

L97.203

L97.204

L97.211

L97.212

L97.213

L97.214

L97.215

L97.216

L97.218

L97.221

L97.222

L97.223

L97.224

L97.225

L97.226

L97.228

L97.301

L97.302

L97.303

L97.304

L97.311

L97.312

L97.313

L97.314

L97.315

L97.316

L97.318

L97.321

L97.322

L97.323

L97.324

L97.325

L97.326

L97.328

L97.401

L97.402

L97.403

L97.404

L97.411

L97.412

L97.413

L97.414

L97.415

L97.416

L97.418

L97.421

L97.422

L97.423

L97.424

L97.425

L97.426

L97.428

L97.501

L97.502

L97.503

L97.504

L97.511

L97.512

L97.513

L97.514

L97.515

L97.516

L97.518

L97.521

L97.522

L97.523

L97.524

L97.525

L97.526

L97.528

L97.801

L97.802

L97.803

L97.804

L97.811

L97.812

L97.813

L97.814

L97.815

L97.816

L97.818

L97.821

L97.822

L97.823

L97.824

L97.825

L97.826

L97.828

L97.901

L97.902

L97.903

L97.904

L97.911

L97.912

L97.913

L97.914

L97.915

L97.916

L97.918

L97.921

L97.922

L97.923

L97.924

L97.925

L97.926

L97.928

Covered Diagnosis Codes for Procedure Codes Q4101, Q4102 and Q4124

L97 codes below must be billed with one of the following codes: I83.0-I83.029, I83.2-I83.229, I87.01-I87.013, I87.03-I87.033, I87.2, I87.31-I87.313, I87.33-I87.333

I83.011

I83.012

I83.013

I83.014

I83.015

I83.018

I83.019

I83.021

I83.022

I83.023

I83.024

I83.025

I83.028

I83.029

I83.211

I83.212

I83.213

I83.214

I83.215

I83.218

I83.219

I83.221

I83.222

I83.223

I83.224

I83.225

I83.228

I83.229

I87.011

I87.012

I87.013

I87.031

I87.032

I87.033

I87.2

I87.311

I87.312

I87.313

I87.331

I87.332

I87.333

L97.111

L97.112

L97.113

L97.114

L97.115

L97.116

L97.118

L97.121

L97.122

L97.123

L97.124

L97.125

L97.126

L97.128

L97.211

L97.212

L97.213

L97.214

L97.215

L97.216

L97.218

L97.221

L97.222

L97.223

L97.224

L97.225

L97.226

L97.228

L97.311

L97.312

L97.313

L97.314

L97.315

L97.316

L97.318

L97.321

L97.322

L97.323

L97.324

L97.325

L97.326

L97.328

L97.411

L97.412

L97.413

L97.414

L97.415

L97.416

L97.418

L97.421

L97.422

L97.423

L97.424

L97.425

L97.426

L97.428

L97.511

L97.512

L97.513

L97.514

L97.515

L97.516

L97.518

L97.521

L97.522

L97.523

L97.524

L97.525

L97.526

L97.528

L97.811

L97.812

L97.813

L97.814

L97.815

L97.816

L97.818

L97.821

L97.822

L97.823

L97.824

L97.825

L97.826

L97.828

L97.911

L97.912

L97.913

L97.914

L97.915

L97.916

L97.918

L97.919

L97.921

L97.922

L97.923

L97.924

L97.925

L97.926

L97.928

L97.929

Covered Diagnosis Codes for Procedure Codes Q4105 and Q4182

T20.20XA

T20.20XD

T20.20XS

T20.211A

T20.211D

T20.211S

T20.212A

T20.212D

T20.212S

T20.22XA

T20.22XD

T20.22XS

T20.23XA

T20.23XD

T20.23XS

T20.24XA

T20.24XD

T20.24XS

T20.25XA

T20.25XD

T20.25XS

T20.26XA

T20.26XD

T20.26XS

T20.27XA

T20.27XD

T20.27XS

T20.29XA

T20.29XD

T20.29XS

T20.30XA

T20.30XD

T20.30XS

T20.311A

T20.311D

T20.311S

T20.312A

T20.312D

T20.312S

T20.32XA

T20.32XD

T20.32XS

T20.33XA

T20.33XD

T20.33XS

T20.34XA

T20.34XD

T20.34XS

T20.35XA

T20.35XD

T20.35XS

T20.36XA

T20.36XD

T20.36XS

T20.37XA

T20.37XD

T20.37XS

T20.39XA

T20.39XD

T20.39XS

T20.60XA

T20.60XD

T20.60XS

T20.611A

T20.611D

T20.611S

T20.612A

T20.612D

T20.612S

T20.62XA

T20.62XD

T20.62XS

T20.63XA

T20.63XD

T20.63XS

T20.64XA

T20.64XD

T20.64XS

T20.65XA

T20.65XD

T20.65XS

T20.66XA

T20.66XD

T20.66XS

T20.67XA

T20.67XD

T20.67XS

T20.69XA

T20.69XD

T20.69XS

T20.70XA

T20.70XD

T20.70XS

T20.711A

T20.711D

T20.711S

T20.712A

T20.712D

T20.712S

T20.72XA

T20.72XD

T20.72XS

T20.73XA

T20.73XD

T20.73XS

T20.74XA

T20.74XD

T20.74XS

T20.75XA

T20.75XD

T20.75XS

T20.76XA

T20.76XD

T20.76XS

T20.77XA

T20.77XD

T20.77XS

T20.79XA

T20.79XD

T20.79XS

T21.21XA

T21.21XD

T21.21XS

T21.22XA

T21.22XD

T21.22XS

T21.23XA

T21.23XD

T21.23XS

T21.24XA

T21.24XD

T21.24XS

T21.25XA

T21.25XD

T21.25XS

T21.26XA

T21.26XD

T21.26XS

T21.27XA

T21.27XD

T21.27XS

T21.29XA

T21.29XD

T21.29XS

T21.31XA

T21.31XD

T21.31XS

T21.32XA

T21.32XD

T21.32XS

T21.33XA

T21.33XD

T21.33XS

T21.34XA

T21.34XD

T21.34XS

T21.35XA

T21.35XD

T21.35XS

T21.36XA

T21.36XD

T21.36XS

T21.37XA

T21.37XD

T21.37XS

T21.39XA

T21.39XD

T21.39XS

T21.61XA

T21.61XD

T21.61XS

T21.62XA

T21.62XD

T21.62XS

T21.63XA

T21.63XD

T21.63XS

T21.64XA

T21.64XD

T21.64XS

T21.65XA

T21.65XD

T21.65XS

T21.66XA

T21.66XD

T21.66XS

T21.67XA

T21.67XD

T21.67XS

T21.69XA

T21.69XD

T21.69XS

T21.71XA

T21.71XD

T21.71XS

T21.72XA

T21.72XD

T21.72XS

T21.73XA

T21.73XD

T21.73XS

T21.74XA

T21.74XD

T21.74XS

T21.75XA

T21.75XD

T21.75XS

T21.76XA

T21.76XD

T21.76XS

T21.77XA

T21.77XD

T21.77XS

T21.79XA

T21.79XD

T21.79XS

T22.20XA

T22.20XD

T22.20XS

T22.211A

T22.211D

T22.211S

T22.212A

T22.212D

T22.212S

T22.221A

T22.221D

T22.221S

T22.222A

T22.222D

T22.222S

T22.231A

T22.231D

T22.231S

T22.232A

T22.232D

T22.232S

T22.241A

T22.241D

T22.241S

T22.242A

T22.242D

T22.242S

T22.251A

T22.251D

T22.251S

T22.252A

T22.252D

T22.252S

T22.261A

T22.261D

T22.261S

T22.262A

T22.262D

T22.262S

T22.291A

T22.291D

T22.291S

T22.292A

T22.292D

T22.292S

T22.30XA

T22.30XD

T22.30XS

T22.311A

T22.311D

T22.311S

T22.312A

T22.312D

T22.312S

T22.321A

T22.321D

T22.321S

T22.322A

T22.322D

T22.322S

T22.331A

T22.331D

T22.331S

T22.332A

T22.332D

T22.332S

T22.341A

T22.341D

T22.341S

T22.342A

T22.342D

T22.342S

T22.351A

T22.351D

T22.351S

T22.352A

T22.352D

T22.352S

T22.361A

T22.361D

T22.361S

T22.362A

T22.362D

T22.362S

T22.391A

T22.391D

T22.391S

T22.392A

T22.392D

T22.392S

T22.60XA

T22.60XD

T22.60XS

T22.611A

T22.611D

T22.611S

T22.612A

T22.612D

T22.612S

T22.621A

T22.621D

T22.621S

T22.622A

T22.622D

T22.622S

T22.631A

T22.631D

T22.631S

T22.632A

T22.632D

T22.632S

T22.641A

T22.641D

T22.641S

T22.642A

T22.642D

T22.642S

T22.651A

T22.651D

T22.651S

T22.652A

T22.652D

T22.652S

T22.661A

T22.661D

T22.661S

T22.662A

T22.662D

T22.662S

T22.691A

T22.691D

T22.691S

T22.692A

T22.692D

T22.692S

T22.70XA

T22.70XD

T22.70XS

T22.711A

T22.711D

T22.711S

T22.712A

T22.712D

T22.712S

T22.721A

T22.721D

T22.721S

T22.722A

T22.722D

T22.722S

T22.731A

T22.731D

T22.731S

T22.732A

T22.732D

T22.732S

T22.741A

T22.741D

T22.741S

T22.742A

T22.742D

T22.742S

T22.751A

T22.751D

T22.751S

T22.752A

T22.752D

T22.752S

T22.761A

T22.761D

T22.761S

T22.762A

T22.762D

T22.762S

T22.791A

T22.791D

T22.791S

T22.792A

T22.792D

T22.792S

T23.201A

T23.201D

T23.201S

T23.202A

T23.202D

T23.202S

T23.211A

T23.211D

T23.211S

T23.212A

T23.212D

T23.212S

T23.221A

T23.221D

T23.221S

T23.222A

T23.222D

T23.222S

T23.231A

T23.231D

T23.231S

T23.232A

T23.232D

T23.232S

T23.241A

T23.241D

T23.241S

T23.242A

T23.242D

T23.242S

T23.251A

T23.251D

T23.251S

T23.252A

T23.252D

T23.252S

T23.261A

T23.261D

T23.261S

T23.262A

T23.262D

T23.262S

T23.271A

T23.271D

T23.271S

T23.272A

T23.272D

T23.272S

T23.291A

T23.291D

T23.291S

T23.292A

T23.292D

T23.292S

T23.301A

T23.301D

T23.301S

T23.302A

T23.302D

T23.302S

T23.311A

T23.311D

T23.311S

T23.312A

T23.312D

T23.312S

T23.321A

T23.321D

T23.321S

T23.322A

T23.322D

T23.322S

T23.331A

T23.331D

T23.331S

T23.332A

T23.332D

T23.332S

T23.341A

T23.341D

T23.341S

T23.342A

T23.342D

T23.342S

T23.351A

T23.351D

T23.351S

T23.352A

T23.352D

T23.352S

T23.361A

T23.361D

T23.361S

T23.362A

T23.362D

T23.362S

T23.371A

T23.371D

T23.371S

T23.372A

T23.372D

T23.372S

T23.391A

T23.391D

T23.391S

T23.392A

T23.392D

T23.392S

T23.601A

T23.601D

T23.601S

T23.602A

T23.602D

T23.602S

T23.611A

T23.611D

T23.611S

T23.612A

T23.612D

T23.612S

T23.621A

T23.621D

T23.621S

T23.622A

T23.622D

T23.622S

T23.631A

T23.631D

T23.631S

T23.632A

T23.632D

T23.632S

T23.641A

T23.641D

T23.641S

T23.642A

T23.642D

T23.642S

T23.651A

T23.651D

T23.651S

T23.652A

T23.652D

T23.652S

T23.661A

T23.661D

T23.661S

T23.662A

T23.662D

T23.662S

T23.671A

T23.671D

T23.671S

T23.672A

T23.672D

T23.672S

T23.691A

T23.691D

T23.691S

T23.692A

T23.692D

T23.692S

T23.701A

T23.701D

T23.701S

T23.702A

T23.702D

T23.702S

T23.711A

T23.711D

T23.711S

T23.712A

T23.712D

T23.712S

T23.721A

T23.721D

T23.721S

T23.722A

T23.722D

T23.722S

T23.731A

T23.731D

T23.731S

T23.732A

T23.732D

T23.732S

T23.741A

T23.741D

T23.741S

T23.742A

T23.742D

T23.742S

T23.751A

T23.751D

T23.751S

T23.752A

T23.752D

T23.752S

T23.761A

T23.761D

T23.761S

T23.762A

T23.762D

T23.762S

T23.771A

T23.771D

T23.771S

T23.772A

T23.772D

T23.772S

T23.791A

T23.791D

T23.791S

T23.792A

T23.792D

T23.792S

T24.201A

T24.201D

T24.201S

T24.202A

T24.202D

T24.202S

T24.211A

T24.211D

T24.211S

T24.212A

T24.212D

T24.212S

T24.221A

T24.221D

T24.221S

T24.222A

T24.222D

T24.222S

T24.231A

T24.231D

T24.231S

T24.232A

T24.232D

T24.232S

T24.291A

T24.291D

T24.291S

T24.292A

T24.292D

T24.292S

T24.301A

T24.301D

T24.301S

T24.302A

T24.302D

T24.302S

T24.311A

T24.311D

T24.311S

T24.312A

T24.312D

T24.312S

T24.321A

T24.321D

T24.321S

T24.322A

T24.322D

T24.322S

T24.331A

T24.331D

T24.331S

T24.332A

T24.332D

T24.332S

T24.391A

T24.391D

T24.391S

T24.392A

T24.392D

T24.392S

T24.601A

T24.601D

T24.601S

T24.602A

T24.602D

T24.602S

T24.611A

T24.611D

T24.611S

T24.612A

T24.612D

T24.612S

T24.621A

T24.621D

T24.621S

T24.622A

T24.622D

T24.622S

T24.631A

T24.631D

T24.631S

T24.632A

T24.632D

T24.632S

T24.691A

T24.691D

T24.691S

T24.692A

T24.692D

T24.692S

T24.701A

T24.701D

T24.701S

T24.702A

T24.702D

T24.702S

T24.711A

T24.711D

T24.711S

T24.712A

T24.712D

T24.712S

T24.721A

T24.721D

T24.721S

T24.722A

T24.722D

T24.722S

T24.731A

T24.731D

T24.731S

T24.732A

T24.732D

T24.732S

T24.791A

T24.791D

T24.791S

T24.792A

T24.792D

T24.792S

T25.211A

T25.211D

T25.211S

T25.212A

T25.212D

T25.212S

T25.221A

T25.221D

T25.221S

T25.222A

T25.222D

T25.222S

T25.231A

T25.231D

T25.231S

T25.232A

T25.232D

T25.232S

T25.291A

T25.291D

T25.291S

T25.292A

T25.292D

T25.292S

T25.311A

T25.311D

T25.311S

T25.312A

T25.312D

T25.312S

T25.321A

T25.321D

T25.321S

T25.322A

T25.322D

T25.322S

T25.331A

T25.331D

T25.331S

T25.332A

T25.332D

T25.332S

T25.391A

T25.391D

T25.391S

T25.392A

T25.392D

T25.392S

T25.611A

T25.611D

T25.611S

T25.612A

T25.612D

T25.612S

T25.621A

T25.621D

T25.621S

T25.622A

T25.622D

T25.622S

T25.631A

T25.631D

T25.631S

T25.632A

T25.632D

T25.632S

T25.691A

T25.691D

T25.691S

T25.692A

T25.692D

T25.692S

T25.711A

T25.711D

T25.711S

T25.712A

T25.712D

T25.712S

T25.721A

T25.721D

T25.721S

T25.722A

T25.722D

T25.722S

T25.731A

T25.731D

T25.731S

T25.732A

T25.732D

T25.732S

T25.791A

T25.791D

T25.791S

T25.792A

T25.792D

T25.792S

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Medical Review 6-15-2020 - Coding HCPCS Updates - Effective July 01, 2020

Internal Medical Policy Committee 9-22-2020 Coding update:

Added procedure codes Q4102 and Q4124 under section involving 'Treatment of chronic, noninfected, full-thickness diabetic lower extremity ulcers'

Added procedure code Q4124 under section regarding 'Treatment of chronic, non-infected, partial- or full-thickness lower extremity skin ulcers due to venous insufficiency'

Removed procedure code Q4124 from section regarding: ALL other skin and soft tissue substitutes

Internal Medical Policy Committee 1-19-2021 Coding update

Removed Procedure code 19366

Internal Medical Policy Committee 11-23-2021 Coding update-

Added Procedure codes A2001, A2002, A2003, A2004, A2005, A2006, A2007, A2008, A2009, A2010

Internal Medical Policy Committee 3-23-2022 Coding update- Effective April 01, 2022

Added Procedure codes A2011, A2012, A2013 and A4100
Removed BIO-connect and Procedure code A2003

Internal Medical Policy Committee 7-21-2022 Revision

Removed Product names

Internal Medical Policy Committee 9-28-2022 Coding update - Effective October 01, 2022

Added Procedure codes A2014; A2015; A2016; A2017 and A2018.

Internal Medical Policy Committee 11-29-2022 Coding update - Effective January 01, 2023

Removed procedure code C1849

Internal Medical Policy Committee 3-23-2023 Coding update - Effective April 01, 2023

Added procedure codes A2019; A2020 and A2021

Internal Medical Policy Committee 11-15-2023 Coding update - Effective October 01, 2023

Added procedure codes A2024; A2025; Q4178; Q4180; Q4181 and Q4204.

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