Q4106 Dermagraft

Dermagraft, per square centimeter

Payer policies and prior authorization for Q4106

19 of 20 payer prior-auth lists that name Q4106 require prior authorization or set conditions: Blue Cross and Blue Shield of Illinois, HealthSpring, Humana, Molina Complete Care (Virginia), Molina Healthcare of Idaho, Molina Healthcare of Iowa, Molina Healthcare of Mississippi, Molina Healthcare of Nevada, Molina Healthcare of Ohio, Molina Healthcare of Texas, Molina Healthcare of Utah, Rocky Mountain Health Plans, UnitedHealthcare Community Plan.

PayerPlanStatePrior authConditionsSinceSource
Blue Cross and Blue Shield of IllinoisBlue Cross Community Health Plans (BCCHP), Illinois MedicaidILprior auth requiredJan 1, 2023Illinois Medicaid Prior Authorization Code List, Effective 10/1/2026
Blue Cross and Blue Shield of IllinoisBlue Cross Community MMAI (Medicare-Medicaid Alignment Initiative)ILprior auth requiredJan 1, 2023Procedure Code List, Effective 1/1/2025
HealthSpringMedicare AdvantageAllprior auth requiredAug 1, 20262026 Q4 Prior Authorization List
HumanaHumana Healthy HorizonsINprior auth requiredJan 1, 20271 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
HumanaHumana Puerto Rico MA and Dual Medicare-MedicaidPRprior auth requiredNov 3, 2025Puerto Rico Medicare Advantage and Dual Medicare-Medicaid Plans Preauthorization and Notification List Puerto Rico Medicare Advantage and Dual Medicare-Medicaid Plan Preauthorization and Notification
HumanaOak Street HealthAllprior auth requiredOak Street Health (Humana): Prior Authorization List (PAL) Codes Under Management
Molina Complete Care (Virginia)MedicaidVAprior auth requiredApr 1, 2025Virginia Medicaid PA Code Matrix and Virginia code/benefit exceptions, effective Q2 2025
Molina Healthcare of IdahoMedicaidIDprior auth requiredJan 1, 2025Idaho Medicaid Prior Auth (PA) Code Matrix and Idaho code/benefit exceptions, Q1 2025
Molina Healthcare of IowaMedicaidIAprior auth requiredJul 1, 2023IA Prior Authorization Matrix, effective Q3 2023
Molina Healthcare of MississippiMedicaidMSprior auth requiredJan 1, 2025Mississippi Medicaid Prior Auth (PA) Code Matrix and exceptions, effective Q1 2025
Molina Healthcare of NevadaMedicaidNVprior auth requiredOct 1, 2022Medicaid Prior Auth (PA) Code Matrix, effective Q4 2022
Molina Healthcare of OhioMedicaid and MyCare Ohio (MMP) MedicaidOHprior auth requiredOct 1, 2023Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01
Molina Healthcare of OhioMedicare and MyCare Ohio (MMP) MedicareOHprior auth requiredOct 1, 2023Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01
Molina Healthcare of OhioExchangeOHprior auth requiredOct 1, 2023Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01
Molina Healthcare of TexasSTARTXprior auth requiredFeb 19, 2025Molina Healthcare of Texas Prior Authorization Annual Review Report (STAR), reviewed 2025-02-19
Molina Healthcare of TexasSTAR+PLUSTXprior auth requiredFeb 19, 2025Molina Healthcare of Texas Prior Authorization Annual Review Report (STAR+PLUS), reviewed 2025-02-19
Molina Healthcare of UtahMedicaidUTprior auth requiredJan 1, 2025Utah Medicaid Prior Auth (PA) Code Matrix and Utah code/benefit exceptions, Q1 2025
Rocky Mountain Health PlansRocky Mountain Medicare Advantage D-SNPCOprior auth requiredFeb 1, 2025Rocky Mountain Health Plans Medicare Advantage Dual-Special Needs Plans – prior authorization Effective February 1, 2025
UnitedHealthcare Community PlanLouisiana Medicaid (Healthy Louisiana)LAprior auth requiredJan 1, 2026Prior authorization requirements for UnitedHealthcare Community Plan of Louisiana

Payer coverage policies that name Q4106

Q4106 appears in 9 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), Regence, UnitedHealthcare.

PayerPolicyRole in policyReviewedDocument
AetnaMohs Micrographic Surgery (0383)listed, no stance (range Q4100-Q4255)May 28, 2026payer document
Blue Cross & Blue Shield of MississippiBioengineered Skin And Soft Tissue Substitutes (A.7.01.113)covered if criteria are metpayer document
Blue Cross NCSkin and Soft Tissue Substituteslisted, no stance (range Q4100-Q4108)Aug 1, 2026payer document
Blue Shield of CaliforniaBioengineered Skin and Soft Tissue Substitutes (7.01.113)listed, no stancepayer document
CenteneSkin and Soft Tissue Substitutes (CP.MP.185)not coveredApr 1, 2026payer document
CignaTissue-Engineered Skin Substitutes (0068)covered if criteria are metJun 15, 2026payer 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 stanceJul 1, 2026payer document
RegenceBioengineered Skin and Soft Tissue Substitutes and Amniotic Products (Medicine 170)listed, no stanceJun 1, 2026payer document
UnitedHealthcareSkin and Soft Tissue Substitutes (for North Carolina Only) (CSNCT0592.11)listed, no stanceApr 1, 2026payer document

Recent prior-auth changes

  • Aug 1, 2026: PA added, HealthSpring
  • Jul 1, 2026: PA removed, Molina Healthcare of Texas
  • Apr 1, 2026: PA removed, Blue Cross and Blue Shield of New Mexico
  • Apr 1, 2026: PA removed, Blue Cross and Blue Shield of New Mexico
  • Apr 1, 2026: PA removed, HealthSpring
  • Jan 1, 2026: PA removed, Molina Healthcare of Illinois
  • Jan 1, 2026: PA removed, Molina Healthcare of Michigan
  • Jan 1, 2026: PA removed, Humana
  • Jan 1, 2026: PA removed, Humana
  • Jan 1, 2026: PA removed, Humana

Medicaid fee-for-service

  • FL: $40.51 (physician, non-facility), effective Jan 1, 2026
  • KY: $0.00 (asc), effective Jan 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.