`Q4114` Integra flowable wound matri

Integra flowable wound matrix, injectable, 1 cc

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

Medicare pricing for Q4114

Physician Fee Schedule (CY 2026, RVU26D)

Status C: contractor-priced by the MAC.

Payer policies and prior authorization for Q4114

37 of 37 payer prior-auth lists that name Q4114 require prior authorization or set conditions: Blue Cross and Blue Shield of New Mexico, Blue Shield of California, CarePlus Health Plans, Cigna, 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
Cigna	ACA/IFP	All	prior auth required	May be delegated to eviCore for some clients	Jan 1, 2009	Master Precertification List (For Health Care Providers)
Cigna	Basic Standard	All	prior auth required	May be delegated to eviCore for some clients	Jan 1, 2009	Master Precertification List (For Health Care Providers)
Cigna	Complete/PHS+/Preferred	All	prior auth required	May be delegated to eviCore for some clients	Jan 1, 2009	Master Precertification List (For Health Care Providers)
Cigna	Other Services	All	prior auth required	Experimental/investigational	Mar 7, 2026	Cigna Commercial Prior Authorization Procedure Code List: Other Services
Cigna	Other Services	All	prior auth required	Experimental/investigational	Mar 7, 2026	Cigna Commercial Comprehensive CPT Code Reference for Prior Authorization Across All Programs
Blue Cross and Blue Shield of New Mexico	Turquoise Care (New Mexico Medicaid)	NM	prior auth required		Jan 1, 2023	New Mexico Medicaid Benefit Preauthorization Procedure Code List 10/1/26
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	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 Health Plans CHP+	CO	prior auth required		Oct 1, 2026	Rocky Mountain Children’s Health Plan - prior authorization Effective October 1, 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 Q4114

Q4114 appears in 23 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, Cigna, Health Care Service Corporation (BCBS IL, TX, OK, NM, MT), 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
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)	covered if criteria are met		payer document
Blue Cross Blue Shield of Massachusetts	Bioengineered Skin and Soft Tissue Substitutes (663)	covered if criteria are met		payer document
Blue Cross NC	Skin and Soft Tissue Substitutes	listed, no stance (range Q4110-Q4118)	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)	not covered	Apr 1, 2026	payer document
Cigna	Tissue-Engineered Skin Substitutes (0068)	unproven / investigational	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
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 Idaho Only) (CS153ID.E)	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 Jersey Only) (CS153NJ.X)	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
Oct 1, 2026: PA removed, Oxford Health Plans
Jul 1, 2026: PA added, Humana
Jul 1, 2026: PA added, Molina Healthcare of Texas
Jul 1, 2026: PA added, Humana
Mar 1, 2026: PA removed, Humana
Jan 1, 2026: PA added, Molina Healthcare of Michigan
Jan 1, 2026: PA added, Molina Healthcare of Illinois
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 OH.

CO: $370.00 (chp_plus, non-facility), effective Jul 1, 2026
IL: $1520.13 (practitioner), effective Apr 1, 2023
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: $1494.41 (provider_administered_drugs), effective Jul 1, 2026
TX: $1542.24 (physician, Physician, non-facility), effective Mar 1, 2026
VA: $1494.41 (medical), effective Oct 1, 2025
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.

Q4114 Integra flowable wound matri