`A4100` Nosht skin sub fda clrd nos

Non-sheet form skin substitute, fda cleared as a device, not otherwise specified (list in addition to primary procedure)

Medicare coverage: Carrier judgment
Status: active (October 2026 file)

Medicare pricing for A4100

Physician Fee Schedule (CY 2026, RVU26D)

Status C: contractor-priced by the MAC.

Payer policies and prior authorization for A4100

31 of 31 payer prior-auth lists that name A4100 require prior authorization or set conditions: Blue Shield of California, CarePlus Health Plans, Humana, Molina Healthcare of California, Molina Healthcare of Illinois, Molina Healthcare of Iowa, Molina Healthcare of Michigan, Molina Healthcare of Nevada, Molina Healthcare of New Mexico, Molina Healthcare of Ohio, Molina Healthcare of Texas, Passport by Molina Healthcare (Kentucky), Rocky Mountain Health Plans.

Payer	Plan	State	Prior auth	Conditions	Since	Source
Blue Shield of California	Blue Shield Medicare	CA	prior auth required		Sep 1, 2026	Prior Authorization List for Blue Shield Medicare
CarePlus Health Plans	CarePlus Health Plans	FL	prior auth required		Jan 1, 2027	Medicare Advantage and Dual Eligible Special Needs Plans Prior Authorization and Notification List
Humana	Humana D-SNP (FL)	FL	prior auth required		Jan 1, 2027	1 *New prior authorization requirement 787403FL0725 FLHMQSREN Humana Dual Fully Integrated Florida Prior Authorization and Notification List
Humana	Humana D-SNP (IL)	IL	prior auth required		Jan 1, 2027	Humana Dual Fully Integrated Illinois Prior Authorization and Notification List
Humana	Humana D-SNP (IN)	IN	prior auth required		Jan 1, 2027	*New prior authorization requirement 814403IN0825 H4939_INHN6Z6EN_C Humana PathWays Dual Care (HMO-POS D-SNP) Indiana Prior Authorization and Notification List
Humana	Humana D-SNP (MI)	MI	prior auth required		Jan 1, 2027	1 Humana Dual Highly Integrated Michigan Prior Authorization and Notification List
Humana	Humana D-SNP (SC)	SC	prior auth required		Jan 1, 2027	Humana Dual Highly Integrated South Carolina Prior Authorization and Notification List
Humana	Humana D-SNP (VA)	VA	prior auth required		Jan 1, 2027	Virginia Prior Authorization and Notification List
Humana	Humana Healthy Horizons	IN	prior auth required		Jan 1, 2027	1 Humana Healthy Horizons® in Indiana Preauthorization and Notification List (PAL) for Indiana PathWays for Aging Please note the term prior authorization when used in this communication, is defined a
Humana	Humana Healthy Horizons	OH	prior auth required		Jan 1, 2027	555201OH0924-B OHHMZG2EN Humana Healthy Horizons® in Ohio Prior Authorization Notification List (PAL) The following preauthorization and notification list
Humana	Humana Healthy Horizons	VA	prior auth required		Jan 1, 2027	Humana Healthy Horizons in Virginia Prior Authorization and Notification List (PAL)
Humana	Humana MA and D-SNP	All	prior auth required		Jan 1, 2027	Medicare Advantage and Dual Eligible Special Needs Plans Prior Authorization and Notification List
Humana	Humana Puerto Rico MA and Dual Medicare-Medicaid	PR	prior auth required		Nov 3, 2025	Puerto Rico Medicare Advantage and Dual Medicare-Medicaid Plans Preauthorization and Notification List Puerto Rico Medicare Advantage and Dual Medicare-Medicaid Plan Preauthorization and Notification
Humana	Oak Street Health	All	prior auth required			Oak Street Health (Humana): Prior Authorization List (PAL) Codes Under Management
Molina Healthcare of California	Medicaid	CA	prior auth required		Apr 1, 2026	Medicaid Prior Auth (PA) Code Matrix (California), effective Q2 2026
Molina Healthcare of Illinois	Medicaid	IL	prior auth required		Nov 1, 2025	Molina Healthcare of Illinois Codification Grid Q3 2026
Molina Healthcare of Iowa	Medicaid	IA	prior auth required		Jul 1, 2023	IA Prior Authorization Matrix, effective Q3 2023
Molina Healthcare of Michigan	Medicare Advantage	MI	prior auth required		Jul 1, 2026	Molina Healthcare of Michigan PA Matrix 2026-Q3
Molina Healthcare of Michigan	Medicaid	MI	prior auth required		Jul 1, 2026	Molina Healthcare of Michigan PA Matrix 2026-Q3
Molina Healthcare of Nevada	Medicaid	NV	prior auth required		Oct 1, 2022	Medicaid Prior Auth (PA) Code Matrix, effective Q4 2022
Molina Healthcare of New Mexico	Medicaid	NM	prior auth required		Oct 1, 2025	New Mexico Medicaid Prior Auth (PA) Code Matrix, effective July 1, 2026
Molina Healthcare of Ohio	Medicaid and MyCare Ohio (MMP) Medicaid	OH	prior auth required		Oct 1, 2023	Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01
Molina Healthcare of Ohio	Medicaid and MyCare Ohio (MMP) Medicaid	OH	prior auth required		Oct 1, 2023	Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01
Molina Healthcare of Ohio	Medicare and MyCare Ohio (MMP) Medicare	OH	prior auth required		Oct 1, 2023	Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01
Molina Healthcare of Ohio	Medicare and MyCare Ohio (MMP) Medicare	OH	prior auth required		Oct 1, 2023	Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01
Molina Healthcare of Ohio	Exchange	OH	prior auth required		Oct 1, 2023	Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01
Molina Healthcare of Ohio	Exchange	OH	prior auth required		Oct 1, 2023	Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01
Molina Healthcare of Texas	STAR, STAR+PLUS, STAR Kids, CHIP (Medicaid PA code matrix)	TX	prior auth required	Refer to Texas Medicaid Provider Procedures Manual for skin substitute limitations	Oct 1, 2025	Medicaid Behavioral Health and Medical Prior Authorization (PA) Code Matrix (Texas), 2026-Q3
Molina Healthcare of Texas	Exchange	TX	prior auth required	PA Modernization - PA requirements will be removed where covered	Jan 1, 2024	Marketplace Prior Authorization (PA) Code Matrix (Texas), effective July 1, 2026
Passport by Molina Healthcare (Kentucky)	Medicaid	KY	prior auth required		Oct 1, 2025	Kentucky Medicaid Prior Auth (PA) Code Matrix and Kentucky PA Code Exceptions, effective Q3 2026
Rocky Mountain Health Plans	Rocky Mountain Medicare Advantage D-SNP	CO	prior auth required		Feb 1, 2025	Rocky Mountain Health Plans Medicare Advantage Dual-Special Needs Plans – prior authorization Effective February 1, 2025

Payer coverage policies that name A4100

A4100 appears in 20 coverage policies from Aetna, Anthem, Blue Cross & Blue Shield of Mississippi, Blue Cross Blue Shield of Massachusetts, Blue Cross NC, Blue Shield of California, Centene, Premera Blue Cross, Regence, UnitedHealthcare.

Payer	Policy	Role in policy	Reviewed	Document
Aetna	Mohs Micrographic Surgery (0383)	listed, no stance	May 28, 2026	payer document
Aetna	Skin and Soft Tissue Substitutes (0244)	not covered	Jul 29, 2026	payer document
Anthem	Products for Wound Healing and Soft Tissue Grafting: Investigational (SURG.00011)	unproven / investigational	Aug 13, 2026	payer document
Blue Cross & Blue Shield of Mississippi	Bioengineered Skin And Soft Tissue Substitutes (A.7.01.113)	unproven / investigational		payer document
Blue Cross Blue Shield of Massachusetts	Bioengineered Skin and Soft Tissue Substitutes (663) Procedure	unproven / investigational		payer document
Blue Cross NC	Skin and Soft Tissue Substitutes	listed, no stance	Aug 1, 2026	payer document
Blue Shield of California	Bioengineered Skin and Soft Tissue Substitutes (7.01.113)	listed, no stance		payer document
Centene	Skin and Soft Tissue Substitutes (CP.MP.185) OrCel	covered if criteria are met	Apr 1, 2026	payer document
Premera Blue Cross	Bioengineered Skin and Soft Tissue Substitutes (7.01.582) Reviewed for Medical Necessity	listed, no stance	Oct 1, 2026	payer document
Regence	Bioengineered Skin and Soft Tissue Substitutes and Amniotic Products (Medicine 170)	listed, no stance	Jun 1, 2026	payer document
UnitedHealthcare	Skin Substitutes Grafts/Cellular and Tissue-Based Products (Injections and/or Applications) (MMP105.22)	listed, no stance	Aug 1, 2026	payer document
UnitedHealthcare	Skin and Soft Tissue Substitutes (2026T0592HH)	listed, no stance	Aug 1, 2026	payer document
UnitedHealthcare	Skin and Soft Tissue Substitutes (CS153.AB)	listed, no stance	Aug 1, 2026	payer document
UnitedHealthcare	Skin and Soft Tissue Substitutes (for Kansas Only) (CS153KS.05)	listed, no stance	Aug 1, 2026	payer document
UnitedHealthcare	Skin and Soft Tissue Substitutes (for Kentucky Only) (CS153KY.21)	listed, no stance	Aug 1, 2026	payer document
UnitedHealthcare	Skin and Soft Tissue Substitutes (for Nebraska Only) (CS153NE.V)	listed, no stance	Aug 1, 2026	payer document
UnitedHealthcare	Skin and Soft Tissue Substitutes (for New Mexico Only) (CS153NM.H)	listed, no stance	Aug 1, 2026	payer document
UnitedHealthcare	Skin and Soft Tissue Substitutes (for Ohio Only) (CS153OH.I)	listed, no stance	Apr 1, 2026	payer document
UnitedHealthcare	Skin and Soft Tissue Substitutes (for Pennsylvania Only) (CS153PA.Y)	listed, no stance	Aug 1, 2026	payer document
UnitedHealthcare	Skin and Soft Tissue Substitutes (for Tennessee Only) (CS153TN.Z)	listed, no stance	Aug 1, 2026	payer document

Recent prior-auth changes

Jan 1, 2027: PA added, Humana
Jan 1, 2027: PA added, Humana
Jan 1, 2027: PA added, Humana
Oct 1, 2026: PA removed, Oxford Health Plans
Jul 1, 2026: PA added, Molina Healthcare of Texas
Mar 1, 2026: PA removed, Humana
Jan 1, 2026: PA added, Molina Healthcare of Michigan
Jan 1, 2026: PA added, Molina Healthcare of Michigan
Jan 1, 2026: PA added, Molina Healthcare of Illinois
Oct 1, 2025: PA added, Passport by Molina Healthcare (Kentucky)

Medicaid fee-for-service

IN: $42.97 (professional, Advanced Practice Nurse (85%), non-facility), effective Jan 1, 2026
KY: $0.00 (asc), effective Jan 1, 2026
ND: $0.00 (physician), effective Aug 1, 2026
OH: $92.95 (code_changes), effective Apr 1, 2026
VT: $0.00 (outpatient_hospital_opps), effective Feb 1, 2026
WY: $0.00 (outpatient_hospital_apc, Children's Hospitals), effective Apr 1, 2026

From payers' published prior-auth lists, coverage policies and state Medicaid fee schedules, updated Oct 16, 2026. The role is what the policy's own code table or text says about the code. Not a guarantee of coverage or payment; verify with the payer. CPT® is a registered trademark of the American Medical Association.

A4100 Nosht skin sub fda clrd nos