Q4122 Dermacell, awm, porous sq cmDermacell, dermacell awm or dermacell awm porous, per square centimeter (add-on, list separately in addition to primary procedure)
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.
35 of 35 payer prior-auth lists that name Q4122 require prior authorization or set conditions: Blue Shield of California, CarePlus Health Plans, Cigna, 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 | |
| Cigna | ACA/IFP | All | prior auth required | May be delegated to eviCore for some clients | Jan 1, 2012 | 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, 2012 | Master Precertification List (For Health Care Providers) |
| Cigna | Other Services | All | prior auth under conditions | Add-on code: requested with the primary procedure | Mar 7, 2026 | Cigna Commercial Prior Authorization Procedure Code List: Other Services |
| Cigna | Other Services | All | prior auth under conditions | Add-on code: requested with the primary procedure | Mar 7, 2026 | Cigna Commercial Comprehensive CPT Code Reference for Prior Authorization Across All Programs |
| HealthSpring | Medicare Advantage | All | prior auth required | Jan 1, 2025 | 2026 Q4 Prior Authorization List | |
| CarePlus Health Plans | CarePlus Health Plans | FL | prior auth under conditions | Excludes breast reconstruction following medically necessary mastecto | Jan 1, 2027 | Medicare Advantage and Dual Eligible Special Needs Plans Prior Authorization and Notification 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 under conditions | Excludes breast reconstruction following medically necessary mastecto | 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 under conditions | Excludes breast reconstruction following medically necessary mastecto | Jan 1, 2027 | Humana Dual Fully Integrated Illinois Prior Authorization and Notification List |
| Humana | Humana D-SNP (IN) | IN | prior auth under conditions | Excludes breast reconstruction following medically necessary mastecto | 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 under conditions | Excludes breast reconstruction following medically necessary mastecto | Jan 1, 2027 | 1 Humana Dual Highly Integrated Michigan Prior Authorization and Notification List |
| Humana | Humana D-SNP (SC) | SC | prior auth under conditions | Excludes breast reconstruction following medically necessary mastecto | Jan 1, 2027 | Humana Dual Highly Integrated South Carolina Prior Authorization and Notification List |
| Humana | Humana D-SNP (VA) | VA | prior auth under conditions | Excludes breast reconstruction following medically necessary mastecto | 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 under conditions | Excludes breast reconstruction following medically necessary mastecto | 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 | 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 under conditions | Excludes breast reconstruction following medically necessary mastecto | 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 under conditions | Excludes breast reconstruction following medically necessary mastecto | 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 under conditions | no PA with breast cancerncer dx | Jul 1, 2026 | Molina Healthcare of Michigan PA Matrix 2026-Q3 |
| Molina Healthcare of Michigan | Medicare Advantage | MI | prior auth under conditions | no PA with breast cancerncer dx | 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 | No PA required with breast cancer diagnosis | 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 under conditions | no PA with breast cancerncer dx | 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 |
Q4122 appears in 24 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 | Breast Reconstructive Surgery (0185) | covered if criteria are met | Apr 22, 2026 | payer 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) | covered if criteria are met | payer document | |
| Blue Cross Blue Shield of Massachusetts | Bioengineered Skin and Soft Tissue Substitutes (663) | listed, no stance | payer document | |
| Blue Cross NC | Skin and Soft Tissue Substitutes | listed, no stance (range Q4121-Q4128) | 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) | covered if criteria are met | Apr 1, 2026 | payer document |
| Centene | Skin and Soft Tissue Substitutes (CP.MP.185) | 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 | Tissue-Engineered Skin Substitutes (0068) | covered if criteria are met | 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 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 |
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.