MedicaidMarch 20, 2025
Prior authorization requirement changes
Effective July 1, 2025, prior authorization (PA) requirements will change for the following code(s). The medical code(s) listed below will require PA by Anthem for Medicaid members. Federal and state law, as well as state contract language and Centers for Medicare & Medicaid Services guidelines, including definitions and specific contract provisions/exclusions take precedence over these PA rules and must be considered first when determining coverage.
If the requirements are not met, those services may be deemed ineligible for payment.
Providers may appeal online through Availity Essentials or by calling Provider Services at 800‑407‑4627 (TTY 711) outside L.A. County or 888‑285‑7801 (TTY 711) inside L.A. County with additional information, which may include medical records.
Prior authorization requirements will be added for the following code(s):
Code | Description |
31574 | Laryngoscopy, flexible; with injection(s) for augmentation (such as, percutaneous, transoral), unilateral |
65778 | Placement of amniotic membrane on the ocular surface; without sutures |
65779 | Placement of amniotic membrane on the ocular surface; single layer, sutured |
65780 | Ocular surface reconstruction; amniotic membrane transplantation, multiple layers |
A2006 | Novosorb synpath dermal matrix, per square centimeter |
A2007 | Restrata, per square centimeter |
A2008 | Theragenesis, per square centimeter |
A2009 | Symphony, per square centimeter |
A2010 | Apis, per square centimeter |
A2014 | Omeza collagen matrix, per 100 mg |
A2015 | Phoenix Wound Matrix, per sq cm |
A2016 | Permeaderm b, per square centimeter |
A2017 | PermeaDerm Glove, each |
A2018 | Permeaderm c, per square centimeter |
A2022 | InnovaBurn or InnovaMatrix XL, per sq cm |
A2023 | InnovaMatrix PD, 1 mg |
A2024 | Resolve matrix or xenopatch, per square centimeter |
A2025 | Miro3D, per cu cm |
A2027 | Matriderm, per square centimeter |
A2028 | Micromatrix flex, per mg |
A2029 | Mirotract wound matrix sheet, per cubic centimeter |
A4100 | Skin substitute, FDA-cleared as a device, not otherwise specified |
C1832 | Autograft suspension, including cell processing and application, and all system components |
C9361 | Collagen matrix nerve wrap (NeuroMend Collagen Nerve Wrap), per 0.5 cm length |
Q4117 | Hyalomatrix, per square centimeter |
Q4118 | Matristem micromatrix, 1 mg |
Q4121 | Theraskin, per square centimeter |
Q4151 | Amnioband or guardian, per square centimeter |
Q4154 | Biovance, per square centimeter |
Q4159 | Affinity, per square centimeter |
Q4160 | Nushield, per square centimeter |
Q4166 | Cytal, per square centimeter |
Q4167 | Truskin, per square centimeter |
Q4168 | Amnioband, 1 mg |
Q4169 | Artacent wound, per square centimeter |
Q4170 | Cygnus, per square centimeter |
Q4171 | Interfyl, 1 mg |
Q4173 | Palingen or palingen xplus, per square centimeter |
Q4174 | Palingen or promatrx, 0.36 mg per 0.25 cc |
Q4175 | Miroderm, per square centimeter |
Q4183 | Surgigraft, per sq cm |
Q4184 | Cellesta, per sq cm |
Q4185 | Cellesta Flowable Amnion (25 mg per cc); per 0.5 cc |
Q4186 | Epifix, per sq cm |
Q4187 | Epicord, per sq cm |
Q4188 | AmnioArmor, per sq cm |
Q4189 | Artacent AC, 1 mg |
Q4190 | Artacent AC, per sq cm |
Q4191 | Restorigin, per sq cm |
Q4192 | Restorigin, 1 cc |
Q4193 | Coll-e-Derm, per sq cm |
Q4194 | Novachor, per sq cm |
Q4195 | PuraPly, per sq cm |
Q4196 | PuraPly AM, per sq cm |
Q4197 | PuraPly XT, per sq cm |
Q4198 | Genesis Amniotic Membrane, per sq cm |
Q4199 | Cygnus matrix, per square centimeter |
Q4200 | SkinTE, per sq cm |
Q4201 | Matrion, per sq cm |
Q4202 | Keroxx (2.5g/cc), 1cc |
Q4203 | Derma-Gide, per sq cm |
Q4204 | XWRAP, per sq cm |
Q4205 | Membrane graft or membrane wrap, per square centimeter |
Q4206 | Fluid flow or fluid GF, 1 cc |
Q4208 | Novafix, per square cenitmeter |
Q4209 | Surgraft, per square centimeter |
Q4211 | Amnion bio or Axobiomembrane, per square centimeter |
Q4212 | Allogen, per cc |
Q4213 | Ascent, 0.5 mg |
Q4214 | Cellesta cord, per square centimeter |
Q4215 | Axolotl ambient or axolotl cryo, 0.1 mg |
Q4216 | Artacent cord, per square centimeter |
Q4217 | Woundfix, BioWound, Woundfix Plus, BioWound Plus, Woundfix Xplus or BioWound Xplus, per square centimeter |
Q4218 | Surgicord, per square centimeter |
Q4219 | Surgigraft-dual, per square centimeter |
Q4220 | BellaCell HD or Surederm, per square centimeter |
Q4221 | Amniowrap2, per square centimeter |
Q4222 | Progenamatrix, per square centimeter |
Q4226 | MyOwn skin, includes harvesting and preparation procedures, per square centimeter |
Q4227 | AmnioCoreTM, per sq cm |
Q4229 | Cogenex Amniotic Membrane, per sq cm |
Q4230 | Cogenex Flowable Amnion, per 0.5 cc |
Q4231 | Corplex P, per cc |
Q4232 | Corplex, per sq cm |
Q4233 | SurFactor or NuDyn, per 0.5 cc |
Q4234 | XCellerate, per sq cm |
Q4235 | AMNIOREPAIR or AltiPly, per sq cm |
Q4237 | Cryo-Cord, per sq cm |
Q4238 | Derm-Maxx, per sq cm |
Q4239 | Amnio-Maxx or Amnio-Maxx Lite, per sq cm |
Q4240 | CoreCyte, for topical use only, per 0.5 cc |
Q4241 | PolyCyte, for topical use only, per 0.5 cc |
Q4242 | AmnioCyte Plus, per 0.5 cc |
Q4245 | AmnioText, per cc |
Q4246 | CoreText or ProText, per cc |
Q4247 | Amniotext patch, per sq cm |
Q4248 | Dermacyte Amniotic Membrane Allograft, per sq cm |
Q4251 | Vim, per sq cm |
Q4252 | Vendaje, per sq cm |
Q4253 | Zenith Amniotic Membrane, per sq cm |
Q4259 | Celera dual layer or celera dual membrane, per square centimeter |
Q4260 | Signature apatch, per square centimeter |
Q4261 | Tag, per square centimeter |
Q4272 | Esano a, per square centimeter |
Q4273 | Esano aaa, per square centimeter |
Q4274 | Esano ac, per square centimeter |
Q4275 | Esano aca, per square centimeter |
Q4276 | Orion, per square centimeter |
Q4278 | Epieffect, per square centimeter |
Q4279 | Vendaje ac, per square centimeter |
Q4280 | Xcell amnio matrix, per square centimeter |
Q4281 | Barrera sl or barrera dl, per square centimeter |
Q4282 | Cygnus dual, per square centimeter |
Q4283 | Biovance tri-layer or biovance 3l, per square centimeter |
Q4284 | Dermabind sl, per square centimeter |
Q4285 | NuDYN DL or NuDYN DL MESH, per sq cm |
Q4286 | NuDYN SL or NuDYN SLW, per sq cm |
Q4287 | Dermabind dl, per square centimeter |
Q4288 | Dermabind ch, per square centimeter |
Q4289 | Revoshield + amniotic barrier, per square centimeter |
Q4290 | Membrane Wrap-Hydro, per sq cm |
Q4291 | Lamellas xt, per square centimeter |
Q4292 | Lamellas, per square centimeter |
Q4293 | Acesso dl, per square centimeter |
Q4294 | Amnio quad-core, per square centimeter |
Q4295 | Amnio tri-core amniotic, per square centimeter |
Q4296 | Rebound matrix, per square centimeter |
Q4297 | Emerge matrix, per square centimeter |
Q4298 | Amnicore pro, per square centimeter |
Q4299 | Amnicore pro+, per square centimeter |
Q4300 | Acesso tl, per square centimeter |
Q4301 | Activate matrix, per square centimeter |
Q4302 | Complete aca, per square centimeter |
Q4303 | Complete aa, per square centimeter |
Q4304 | Grafix plus, per square centimeter |
Q4311 | Acesso, per sq cm |
Q4312 | Acesso AC, per sq cm |
Q4313 | DermaBind FM, per sq cm |
Q4314 | Reeva FT, per sq cm |
Q4315 | RegeneLink Amniotic Membrane Allograft, per sq cm |
Q4316 | AmchoPlast, per sq cm |
Q4317 | VitoGraft, per sq cm |
Q4318 | E-Graft, per sq cm |
Q4319 | SanoGraft, per sq cm |
Q4320 | PelloGraft, per sq cm |
Q4321 | RenoGraft, per sq cm |
Q4322 | CaregraFT, per sq cm |
Q4323 | alloPLY, per sq cm |
Q4324 | AmnioTX, per sq cm |
Q4325 | ACApatch, per sq cm |
Q4326 | WoundPlus, per sq cm |
Q4327 | DuoAmnion, per sq cm |
Q4328 | MOST, per sq cm |
Q4329 | Singlay, per sq cm |
Q4330 | TOTAL, per sq cm |
Q4331 | Axolotl Graft, per sq cm |
Q4332 | Axolotl DualGraft, per sq cm |
Q4333 | ArdeoGraft, per sq cm |
Q4334 | Amnioplast 1, per square centimeter |
Q4335 | Amnioplast 2, per square centimeter |
Q4336 | Artacent c, per square centimeter |
Q4337 | Artacent trident, per square centimeter |
Q4338 | Artacent velos, per square centimeter |
Q4339 | Artacent vericlen, per square centimeter |
Q4340 | Simpligraft, per square centimeter |
Q4341 | Simplimax, per square centimeter |
Q4342 | Theramend, per square centimeter |
Q4343 | Dermacyte ac matrix amniotic membrane allograft, per square centimeter |
Q4344 | Tri-membrane wrap, per square centimeter |
Q4345 | Matrix hd allograft dermis, per square centimeter |
To request a PA, you may use one of the following methods:
- Web: once logged in to Availity Essentials at https://Availity.com
- Fax: 800‑754‑4708
- Phone:
- MediCal: 888‑831‑2246
- MRMIP: 877‑273‑4193
Not all PA requirements are listed here. Detailed PA requirements are available to providers at https://providers.anthem.com/ca on the Resources tab or for contracted providers by accessing Availity Essentials at https://Availity.com.
Providers may also call Provider Services at one of the following Customer Care Centers for assistance with PA requirements:
- Outside Los Angeles County: 800‑407‑4627
- Inside Los Angeles County: 888‑285‑7801
UM AROW A2025M2989
Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Blue Cross of California Partnership Plan, Inc. are independent licensees of the Blue Cross Association. Blue Cross of California is contracted with L.A. Care Health Plan to provide Medi-Cal Managed Care services in Los Angeles County. Anthem is a registered trademark of Anthem Insurance Companies, Inc.
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PUBLICATIONS: April 2025 Provider Newsletter
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