`Q4365` Amnio bur dl mem per sq cm

Amnio burgeon dual-layer 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 Q4365

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 Q4365

21 of 21 payer prior-auth lists that name Q4365 require prior authorization or set conditions: Blue Shield of California, Blue Shield of California Promise Health Plan, CarePlus Health Plans, HealthSpring, 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
Blue Shield of California Promise Health Plan	Promise Health Plan Medi-Cal	CA	prior auth required		Sep 1, 2026	Medi-Cal Prior Authorization List
HealthSpring	Medicare Advantage	All	prior auth required		Apr 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	IN	prior auth required	New PA requirement	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 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
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 Q4365

Q4365 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, BlueCross BlueShield of South Carolina, Capital Blue Cross, 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)	listed, no stance		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 Q4346-Q4397)	Aug 1, 2026	payer document
Blue Shield of California	\| Amniotic Membrane and Amniotic Fluid (7.01.149)	listed, no stance		payer document
BlueCross BlueShield of South Carolina	Amniotic Membrane and Amniotic Fluid (CAM 701149)	listed, no stance	Aug 1, 2026	payer document
Capital Blue Cross	Amniotic Membrane and Amniotic Fluid (MP 1.159)	unproven / investigational	Apr 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 \| 13 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 (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 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

Jul 1, 2026: PA added, Molina Healthcare of Texas
Jul 1, 2026: PA added, Humana
Jul 1, 2026: PA added, Humana
Jul 1, 2026: PA added, 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)
May 1, 2025: PA added, Blue Shield of California Promise Health Plan

Medicaid fee-for-service

Prior authorization required or conditional in CO.

CO: $91.83 (chp_plus, non-facility), effective Jul 1, 2026
IN: $42.97 (professional, Advanced Practice Nurse (85%), non-facility), effective Jan 1, 2026
ND: $0.00 (physician), effective Aug 1, 2026
OH: $92.95 (code_changes), effective Jan 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.

Q4365 Amnio bur dl mem per sq cm