Policy Updates Prior AuthorizationMedicare AdvantageMarch 26, 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 Medicare Advantage 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 precertification 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 https://Availity.com or by calling the Provider Services number for Anthem with additional information, which may include medical records.

Prior authorization requirements will be added for the following code(s):

Code

Description

15150

Tissue cultured skin autograft, trunk, arms, legs; first 25 sq cm or less

15155

Tissue cultured skin autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 25 sq cm or less

15271

Application Of Skin Substitute Graft To Trunk, Arms, Legs, Total Wound Surface Area Up To 100 Sq Cm; First 25 Sq Cm Or Less Wound Surface Area

15273

Application Of Skin Substitute Graft To Trunk, Arms, Legs, Total Wound Surface Area Greater Than Or Equal To 100 Sq Cm; First 100 Sq Cm Wound Surface Area, Or 1% Of Body Area

15275

Application Of Skin Substitute Graft To Face, Scalp, Eyelids, Mouth, Neck, Ears, Orbits, Genitalia, Hands, Feet, And/Or Multiple Digits, Total Wound Surface Area Up To 100 Sq

15277

Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area greater than or equal to 100 sq cm; first 100 sq cm wound surface area, or 1% of body area of infants and children

31574

Laryngoscopy, flexible; with injection(s) for augmentation (for example, percutaneous, transoral), unilateral

46707

Repair of anorectal fistula with plug (for example, porcine small intestine submucosa [SIS])

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

A2001

Innovamatrix ac, per square centimeter/Original description: Miscellaneous with Motor >49.15., without comorbidities,10/2019 description: Miscellaneous M >=66.50., without comor

A2002

Mirragen advanced wound matrix, per square centimeter/Original description: Miscellaneous with Motor >38.75 & Motor < 49.15., without comorbidities,10/2019 description: Miscella

A2004

Xcellistem, 1 mg/Original description: Miscellaneous with Motor < 27.85, without comorbidities,10/2019 description: Miscellaneous M < 46.50 and A >=77.50., without comorbidities

A2005

Microlyte matrix, per square centimeter/Miscellaneous M < 46.50 and A < 77.50., without comorbidities

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

A2011

Supra SDRM, per sq cm

A2012

SUPRATHEL, per sq cm

A2013

Innovamatrix FS, per sq cm

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

C1832

Autograft suspension, including cell processing and application, and all system components

C5271

Application of low cost skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area

C5273

Application of low cost skin substitute graft to trunk, arms, legs, total wound surface area greater than or equal to 100 sq cm; first 100 sq cm wound surface area, or 1% of body area of infants and children

C5275

Application of low cost skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area

C5277

Application of low cost skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area greater than or equal to 100 sq cm; first 100 sq cm wound surface area, or 1% of body area of infants and children

C9352

Microporous collagen implantable tube (NeuraGen Nerve Guide), per cm length

C9353

Microporous collagen implantable slit tube (NeuraWrap Nerve Protector), per cm length

C9354

Acellular pericardial tissue matrix of nonhuman origin (Veritas), per sq cm

C9355

Collagen nerve cuff (NeuroMatrix), per 0.5 cm length

C9356

Tendon, porous matrix of cross-linked collagen and glycosaminoglycan matrix (TenoGlide Tendon Protector Sheet), per sq cm

C9358

Dermal substitute, native, nondenatured collagen, fetal bovine origin (SurgiMend Collagen Matrix), per 0.5 sq cm

C9361

Collagen matrix nerve wrap (NeuroMend Collagen Nerve Wrap), per 0.5 cm length

C9363

Skin substitute (Integra Meshed Bilayer Wound Matrix), per square cm

C9364

Porcine implant, Permacol, per sq cm

Q4101

Apligraf, per square centimeter

Q4102

Oasis wound matrix, per square centimeter

Q4103

Oasis burn matrix, per square centimeter

Q4104

Integra bilayer matrix wound dressing (bmwd), per square centimeter

Q4105

Integra dermal regeneration template (DRT) or Integra Omnigraft dermal regeneration matrix, per sq cm

Q4106

Dermagraft, per square centimeter

Q4107

Graftjacket, per square centimeter

Q4108

Integra matrix, per square centimeter

Q4110

Primatrix, per square centimeter

Q4111

Gammagraft, per square centimeter

Q4112

Cymetra, injectable, 1cc

Q4113

GRAFTJACKET XPRESS, injectable, 1cc

Q4114

Integra flowable wound matrix, injectable, 1 cc

Q4115

Alloskin, per square centimeter

Q4116

Alloderm, per square centimeter

Q4117

Hyalomatrix, per square centimeter

Q4118

Matristem micromatrix, 1 mg

Q4121

Theraskin, per square centimeter

Q4122

Dermacell, per square centimeter

Q4124

OASIS ultra tri-layer wound matrix, per sq cm

Q4125

Arthroflex, per sq cm

Q4128

FlexHD, or AllopatchHD, per sq cm

Q4130

Strattice TM, per sq cm

Q4132

Grafix Core and GrafixPL Core, per sq cm

Q4133

Grafix PRIME, GrafixPL PRIME, Stravix and StravixPL, per sq cm

Q4134

Hmatrix, per square centimeter

Q4136

Ez-derm, per square centimeter

Q4137

AmnioExcel, AmnioExcel Plus or BioDExcel, per sq cm

Q4138

Biodfence dryflex, per square centimeter

Q4139

Amniomatrix or biodmatrix, injectable, 1 cc

Q4140

Biodfence, per square centimeter

Q4141

Alloskin ac, per square centimeter

Q4142

Xcm biologic tissue matrix, per square centimeter

Q4143

Repriza, per square centimeter

Q4145

Epifix, injectable, 1 mg

Q4146

Tensix, per square centimeter

Q4147

Architect extracellular matrix, per square centimeter

Q4148

Neox Cord 1K, Neox Cord RT, or Clarix Cord 1K, per sq cm

Q4149

Excellagen, 0.1 cc

Q4150

Allowrap ds or dry, per square centimeter

Q4151

Amnioband or guardian, per square centimeter

Q4152

Dermapure, per square centimeter

Q4153

Dermavest, per square centimeter

Q4154

Biovance, per square centimeter

Q4155

Neoxflo or clarixflo, 1 mg

Q4156

Neox 100 or Clarix 100, per sq cm

Q4157

Revitalon, per square centimeter

Q4158

Kerecis Omega3, per sq cm

Q4159

Affinity, per square centimeter

Q4160

Nushield, per square centimeter

Q4161

Bio-connekt wound matrix, per square centimeter

Q4162

WoundEx Flow, BioSkin Flow, 0.5 cc

Q4163

WoundEx, BioSkin, per sq cm

Q4164

Helicoll, per square centimeter

Q4165

Keramatrix, 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

Q4176

Neopatch or Therion, per sq cm

Q4177

FlowerAmnioFlo, 0.1 cc

Q4178

FlowerAmnioPatch, per sq cm

Q4179

FlowerDerm, per sq cm

Q4180

Revita, per sq cm

Q4181

Amnio Wound, 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

Q4192

Restorigin, 1 cc

Q4195

PuraPly, per sq cm

Q4196

PuraPly AM, per sq cm

Q4197

PuraPly XT, per sq cm

Q4199

Cygnus matrix, per square centimeter

Q4201

Matrion, per sq cm

Q4203

Derma-Gide, per sq cm

Q4205

Membrane graft or membrane wrap, per square centimeter

Q4213

Ascent, 0.5 mg

Q4222

Progenamatrix, per square centimeter

Q4239

Amnio-Maxx or Amnio-Maxx Lite, per sq cm

Q4246

CoreText or ProText, per cc

Q4248

Dermacyte Amniotic Membrane Allograft, per sq cm

Q4250

Amnioamp-mp, per square centimeter

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

Q4261

Tag, per square centimeter

Q4262

Dual layer impax membrane, per square centimeter

Q4264

Cocoon membrane, per square centimeter

Q4285

NuDYN DL or NuDYN DL MESH, per sq cm

Q4286

NuDYN SL or NuDYN SLW, per sq cm

V2790

Amniotic Membrane

Not all PA requirements are listed here. Detailed PA requirements are available for contracted providers by accessing https://Availity.com. Providers may also contact Provider Services via the number on the back of our member ID card for assistance with PA requirements.

UM AROW A2025M2995

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PUBLICATIONS: April 2025 Provider Newsletter