G0681 App of non-sheet skin subApplication of a premarket approval (pma), 510(k), 361 human cells, tissues or cellular and tissue-based products (hct/p) non-sheet form skin substitute for a wound surface area up to 100 sq cm; first 25 sq cm or less of wound surface area
Status C: contractor-priced by the MAC.
1 of 1 payer prior-auth lists that name G0681 require prior authorization or set conditions: Blue Shield of California Promise Health Plan.
| Payer | Plan | State | Prior auth | Conditions | Since | Source |
|---|---|---|---|---|---|---|
| Blue Shield of California Promise Health Plan | Promise Health Plan Medi-Cal | CA | prior auth required | Sep 1, 2026 | Medi-Cal Prior Authorization List |
G0681 appears in 7 coverage policies from Aetna, Anthem, Blue Cross Blue Shield of Massachusetts, Centene, Health Care Service Corporation (BCBS IL, TX, OK, NM, MT), Premera Blue Cross, Regence.
| Payer | Policy | Role in policy | Reviewed | Document |
|---|---|---|---|---|
| Aetna | Skin and Soft Tissue Substitutes (0244) | listed, no stance | 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 Massachusetts | Bioengineered Skin and Soft Tissue Substitutes (663) | listed, no stance | payer document | |
| Centene | Skin and Soft Tissue Substitutes (CP.MP.185) | covered if criteria are met | Apr 1, 2026 | payer document |
| Health Care Service Corporation (BCBS IL, TX, OK, NM, MT) | Bioengineered Skin and Soft Tissue Substitutes (SUR704.012) HCPCS Codes A2002, A2004, A2005, A2006, A2007, A2008, A2009, A2010, A2011, | listed, no stance | Jul 1, 2026 | payer document |
| Premera Blue Cross | Amniotic Membrane and Amniotic Fluid (7.01.583) | unproven / investigational | Jul 13, 2026 | payer document |
| Regence | Bioengineered Skin and Soft Tissue Substitutes and Amniotic Products (Medicine 170) | listed, no stance | Jun 1, 2026 | payer document |
Prior authorization required or conditional in IN, WA.
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.