HCPCS Level II › Q codes Q4264 Cocoon membrane, per sq cmCocoon membrane, per square centimeter (add-on, list separately in addition to primary procedure)
Medicare coverage: Carrier judgment Status: active (October 2026 file) Medicare pricing for Q4264 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 Q4264 26 of 26 payer prior-auth lists that name Q4264 require prior authorization or set conditions: Blue Shield of California, CarePlus Health Plans, Cigna, Humana, Molina Healthcare of California, Molina Healthcare of Illinois, Molina Healthcare of Michigan, Molina Healthcare of New Mexico, Molina Healthcare of Texas, Passport by Molina Healthcare (Kentucky).
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 Cigna ACA/IFP All prior auth required May be delegated to eviCore for some clients Jan 1, 2023 Master Precertification List (For Health Care Providers) Cigna Basic Standard All prior auth required May be delegated to eviCore for some clients Jan 1, 2023 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, 2023 Master Precertification List (For Health Care Providers) Cigna Other Services All prior auth under conditions Experimental/investigational; 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 Experimental/investigational; Add-on code: requested with the primary procedure Mar 7, 2026 Cigna Commercial Comprehensive CPT Code Reference for Prior Authorization Across All Programs 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 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 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 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 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 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
Payer coverage policies that name Q4264 Q4264 appears in 21 coverage policies from Aetna, Anthem, Blue Cross & Blue Shield of Mississippi, Blue Cross Blue Shield of Massachusetts, Blue Cross NC, BlueCross BlueShield of South Carolina, 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 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 Amniotic Membrane And Amniotic Fluid (A.7.01.149) unproven / investigational payer document Blue Cross Blue Shield of Massachusetts Amniotic Membrane and Amniotic Fluid (643) unproven / investigational payer document Blue Cross NC Skin and Soft Tissue Substitutes listed, no stance (range Q4254-Q4271) Aug 1, 2026 payer document BlueCross BlueShield of South Carolina Amniotic Membrane and Amniotic Fluid (CAM 701149) listed, no stance Aug 1, 2026 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) Amniotic Membrane and Amniotic Fluid (SUR704.011)HCPCS Codes A2001, A2035, A2049, Q4132, Q4133, Q4137, Q4138, Q4139, Q4140, listed, no stance Dec 15, 2025 payer document Premera Blue Cross Amniotic Membrane and Amniotic Fluid (7.01.583)Page | 8 of 35 | ∞ unproven / investigational Jul 13, 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 (CS153.AB) 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 (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 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 Jul 1, 2026: PA added, Molina Healthcare of Texas Jul 1, 2026: PA added, Humana 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 Michigan Jan 1, 2026: PA added, Molina Healthcare of Illinois Oct 1, 2025: PA added, Passport by Molina Healthcare (Kentucky) Mar 1, 2025: PA removed, Rocky Mountain Health Plans Medicaid fee-for-service Prior authorization required or conditional in CO.
CO: $30.96 (health_first_colorado), effective Jul 1, 2026 IN: $42.97 (professional, Advanced Practice Nurse (85%), non-facility), effective Jan 1, 2026 KY: $124.11 (asc), effective Jan 1, 2026 ND: $0.00 (physician), effective Aug 1, 2026 OH: $92.95 (code_changes), effective Jan 1, 2026 TX: $372.89 (physician, Physician, non-facility), effective Jun 1, 2026 VT: $0.00 (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.