Q4100 Skin substitute, nosSkin substitute, not otherwise specified
30 of 31 payer prior-auth lists that name Q4100 require prior authorization or set conditions: Blue Cross and Blue Shield of Illinois, Humana, Molina Complete Care (Virginia), Molina Healthcare of Arizona, Molina Healthcare of California, Molina Healthcare of Florida, Molina Healthcare of Idaho, Molina Healthcare of Iowa, Molina Healthcare of Michigan, Molina Healthcare of Mississippi, Molina Healthcare of Nevada, Molina Healthcare of New Mexico, Molina Healthcare of Ohio, Molina Healthcare of South Carolina, Molina Healthcare of Texas, Molina Healthcare of Utah, Molina Healthcare of Washington, Molina Healthcare of Wisconsin, Molina Healthcare, Inc. (national grid).
Q4100 appears in 16 coverage policies from Aetna, Blue Cross & Blue Shield of Mississippi, Blue Cross NC, Blue Shield of California, Centene, Cigna, Health Care Service Corporation (BCBS IL, TX, OK, NM, MT), Premera Blue Cross, Regence, UnitedHealthcare.
| Payer | Policy | Role in policy | Reviewed | Document |
|---|---|---|---|---|
| Aetna | Mohs Micrographic Surgery (0383) | listed, no stance (range Q4100-Q4255) | May 28, 2026 | payer document |
| Blue Cross & Blue Shield of Mississippi | Bioengineered Skin And Soft Tissue Substitutes (A.7.01.113) | covered if criteria are met | payer document | |
| Blue Cross NC | Skin and Soft Tissue Substitutes | listed, no stance (range Q4100-Q4108) | Aug 1, 2026 | payer document |
| Blue Shield of California | Bioengineered Skin and Soft Tissue Substitutes (7.01.113) | listed, no stance | payer document | |
| Centene | Allogeneic Cultured Keratinocytes and Dermal Fibroblasts in Murine Collagen-dsat (StrataGraft) (CP.PHAR.562) | covered if criteria are met | Feb 1, 2026 | payer document |
| Centene | Burn Surgery (CP.MP.186) | covered if criteria are met | Nov 1, 2025 | payer document |
| Centene | Skin and Soft Tissue Substitutes (CP.MP.185) Date | Date | not covered | Apr 1, 2026 | payer document |
| Cigna | Breast Reconstruction Following Mastectomy or Lumpectomy (0178) | covered if criteria are met | Apr 15, 2026 | payer document |
| Cigna | Breast Reconstruction Following Mastectomy or Lumpectomy (0178) | unproven / investigational | Apr 15, 2026 | payer document |
| Cigna | Plantar Fasciitis Treatments (0097) | unproven / investigational | May 15, 2026 | payer document |
| Cigna | Tissue-Engineered Skin Substitutes (0068) | covered if criteria are met | Jun 15, 2026 | payer document |
| Cigna | Tissue-Engineered Skin Substitutes (0068) | unproven / investigational | Jun 15, 2026 | payer document |
| Cigna | Tissue-Engineered Skin Substitutes (0068) | not covered | Jun 15, 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) Page | 4 of 35 | ∞ | unproven / investigational | Jul 13, 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 (for Ohio Only) (CS153OH.I) | listed, no stance | Apr 1, 2026 | payer document |
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.