HCPCS Level II › Q codes Q4107 GraftjacketGraftjacket, per square centimeter (add-on, list separately in addition to primary procedure)
Medicare coverage: Carrier judgment Status: active (October 2026 file) Medicare pricing for Q4107 Physician Fee Schedule (CY 2026, RVU26D) Status A: active, paid separately under the PFS if covered. National amounts: non-facility $127.26, facility $127.26 (total RVUs 3.81 / 3.81 × $33.4009 conversion factor; facility NA: rarely or never done in that setting). Work RVU 0.00, practice expense RVU 3.81 non-facility and 3.81 facility, malpractice RVU 0.00. Global period ZZZ. Qualifying APM participants are paid at a $33.5675 conversion factor.
Payer policies and prior authorization for Q4107 34 of 34 payer prior-auth lists that name Q4107 require prior authorization or set conditions: Blue Cross and Blue Shield of Illinois, Blue Shield of California, CarePlus Health Plans, HealthSpring, 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 Blue Shield of California Blue Shield commercial CA prior auth required Sep 1, 2026 Prior Authorization List for Blue Shield Blue Cross and Blue Shield of Illinois Blue Cross Community Health Plans (BCCHP), Illinois Medicaid IL prior auth required Jan 1, 2023 Illinois Medicaid Prior Authorization Code List, Effective 10/1/2026 Blue Cross and Blue Shield of Illinois Blue Cross Community MMAI (Medicare-Medicaid Alignment Initiative) IL prior auth required Jan 1, 2023 Procedure Code List, Effective 1/1/2025 HealthSpring Medicare Advantage All prior auth required Jan 1, 2025 2026 Q4 Prior Authorization List 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 IL prior auth required Jan 1, 2027 Humana Healthy Horizons in Illinois Prior Authorization and Notification List To view -specific medical coverage policies, please visit Humana Healthy Horizons in Illinois Clinical coverage policies . 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 OK prior auth required Jan 1, 2027 Humana Healthy Horizons® in Oklahoma Prior Authorization Notification List (PAL) The following preauthorization and notification list Humana Humana Healthy Horizons SC prior auth required Jan 1, 2027 Humana Healthy Horizons in South Carolina Prior authorization and Notification List The following list describes services and medications that are commonly reviewed and may require additional clinical 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 Medicaid MI prior auth required Jul 1, 2026 Molina Healthcare of Michigan PA Matrix 2026-Q3 Molina Healthcare of Michigan Medicare Advantage 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 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 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 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 Q4107 Q4107 appears in 9 coverage policies from Aetna, Anthem, Blue Cross & Blue Shield of Mississippi, Blue Cross Blue Shield of Massachusetts, Blue Cross NC, Centene, Health Care Service Corporation (BCBS IL, TX, OK, NM, MT), Regence.
Payer Policy Role in policy Reviewed Document Aetna Mohs Micrographic Surgery (0383) listed, no stance (range Q4100-Q4255) May 28, 2026 payer document Aetna Skin and Soft Tissue Substitutes (0244) covered if criteria are met Jul 29, 2026 payer document Anthem Products for Wound Healing and Soft Tissue Grafting: Medically Necessary Uses (CG-SURG-127) covered if criteria are met 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 (range Q4100-Q4108) Aug 1, 2026 payer document Blue Cross NC Skin and Soft Tissue Substitutes listed, no stance Aug 1, 2026 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 Regence Bioengineered Skin and Soft Tissue Substitutes and Amniotic Products (Medicine 170) listed, no stance Jun 1, 2026 payer document
Recent prior-auth changes Jan 1, 2027: PA added, Humana Jul 1, 2026: PA added, Humana Jul 1, 2026: PA added, Humana Jul 1, 2026: PA added, Humana Jul 1, 2026: PA added, Molina Healthcare of Texas Mar 1, 2026: PA removed, Humana Jan 1, 2026: PA added, Molina Healthcare of Illinois Jan 1, 2026: PA added, Molina Healthcare of Michigan Jan 1, 2026: PA added, Molina Healthcare of Michigan Oct 1, 2025: PA added, Passport by Molina Healthcare (Kentucky) Medicaid fee-for-service Prior authorization required or conditional in MS.
CO: $91.83 (chp_plus, non-facility), effective Jul 1, 2026 IL: $81.33 (practitioner), effective Jan 1, 2026 IN: $42.97 (professional, Advanced Practice Nurse (85%), non-facility), effective Jan 1, 2026 KY: $124.11 (asc), effective Jan 1, 2026 MS: $94.50 (comprehensive), effective Jul 1, 2026 ND: $0.00 (physician), effective Aug 1, 2026 OH: $92.95 (code_changes), effective Jan 1, 2026 OK: $86.69 (physician, non-facility), effective Jul 1, 2026 VA: $90.11 (medical), effective Apr 1, 2019 VT: $96.63 (outpatient_hospital_opps), effective Feb 1, 2026 WY: $55.03 (outpatient_hospital_apc, Ambulatory Surgical Centers), 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.