Q4395 Acelagraft per sq cmAcelagraft, 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.
24 of 24 payer prior-auth lists that name Q4395 require prior authorization or set conditions: Blue Shield of California Promise Health Plan, Cigna, 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 Promise Health Plan | Promise Health Plan Medi-Cal | CA | prior auth required | Sep 1, 2026 | Medi-Cal Prior Authorization List | |
| Cigna | ACA/IFP | All | prior auth required | May be delegated to eviCore for some clients | Oct 1, 2025 | Master Precertification List (For Health Care Providers) |
| Cigna | Basic Standard | All | prior auth required | May be delegated to eviCore for some clients | Oct 1, 2025 | Master Precertification List (For Health Care Providers) |
| Cigna | Complete/PHS+/Preferred | All | prior auth required | May be delegated to eviCore for some clients | Oct 1, 2025 | 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 Comprehensive CPT Code Reference for Prior Authorization Across All Programs |
| 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 |
| HealthSpring | Medicare Advantage | All | prior auth required | Oct 1, 2025 | 2026 Q4 Prior Authorization 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 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 | |
| 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 | Jan 1, 2026 | Molina Healthcare of Illinois Codification Grid Q3 2026 | |
| Molina Healthcare of Michigan | Medicare Advantage | MI | prior auth required | Jul 1, 2026 | Molina Healthcare of Michigan PA Matrix 2026-Q3 | |
| Molina Healthcare of Michigan | Medicaid | 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 | Jan 1, 2026 | 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 | Jan 1, 2026 | Medicaid Behavioral Health and Medical Prior Authorization (PA) Code Matrix (Texas), 2026-Q3 |
| Passport by Molina Healthcare (Kentucky) | Medicaid | KY | prior auth required | Jan 1, 2026 | Kentucky Medicaid Prior Auth (PA) Code Matrix and Kentucky PA Code Exceptions, effective Q3 2026 |
Q4395 appears in 24 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, 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 | Bioengineered Skin And Soft Tissue Substitutes (A.7.01.113) | 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 Q4346-Q4397) | 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 |
| Capital Blue Cross | Experimental and Investigational Procedures (MP 4.002) Procedure codes: Miscellaneous | listed, no stance | Sep 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 | 15 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 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 |
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.