Does Q4105 require prior authorization?

Yes, Q4105 requires prior authorization (medium confidence). Conditional coverage; review criteria to confirm PA need.

What is the Medicare reimbursement rate for Q4105?

Medicare facility rate: N/A. Non-facility rate: N/A. Work RVU: 0.00.

Backwork Sign up free

`Q4105`, Integra dermal regeneration template (drt) or integra omnigraft dermal

HCPCS/CPT

Prior Authorization

Prior Auth Required

Conditional coverage; review criteria to confirm PA need (medium confidence)

Medicare Pricing

Work RVU

0.00

Facility

N/A

Non-Facility

N/A

Documentation Required

For chronic wound indications: documentation of wound duration (e.g., >3, >4, or >6 weeks as required by the specific product) and that standard therapy has failed.
Documentation of standard wound therapy provided and its failure (description of off-loading, wound cleansing/debridement, infection management, compression therapy for venous ulcers, etc.).

For diabetic foot ulcers: documentation of diabetes type (type 1 or 2) and hemoglobin A1c (HbA1c) value demonstrating HbA1c < 12%.

Documentation of adequate blood supply to the treated foot/limb: presence of a palpable pedal pulse or an ankle-brachial index (ABI) >= 0.70.

For additional/continued product applications: documentation of evidence of wound healing (e.g., signs of epithelialization and reduction in ulcer size) to justify permitted additional applications within the policy’s time limits.

For burn indications: documentation of burn depth (partial‑thickness vs deep partial/full‑thickness), documentation of fresh debridement or excision when required, and TBSA when applicable (Epicel requires TBSA >= 30% in line with FDA HDE).

Key Coverage Criteria

InnovaMatrix FD: management of pressure ulcers, diabetic ulcers, vascular ulcers, tunneled/undermined wounds, surgical wounds, trauma wounds and draining wounds.
Wound coverage — autologous skin grafts (CPT 15040-15261) are considered medically necessary for wound coverage.
Wound coverage — unprocessed allogeneic human (cadaver) skin grafts (CPT 15271-15278; HCPCS Q4100) are considered medically necessary for wound coverage.
Wound coverage — unprocessed xenogeneic pig skin grafts (CPT 15271-15278; HCPCS Q4100) are considered medically necessary for wound coverage.
Breast reconstruction — use of acellular dermal matrices/skin substitutes (e.g., AlloDerm Q4116; AlloMax; Cortiva; DermACELL; FlexHD; GalaFLEX scaffolds) is considered medically necessary when used in association with a covered, medically necessary breast reconstruction procedure.
Burn wounds — Biobrane: considered medically necessary when used for temporary covering of a partial-thickness freshly debrided or excised burn wound.

11 Active Policies

HUMANA-SKIN-AND-TISSUE-SUBSTITUTES-LA-MEDICAID, Skin and Tissue Substitutes

HUMANA-SKIN-AND-TISSUE-SUBSTITUTES-VA-MEDICAID, Skin and Tissue Substitutes

ANTHEM-CG-SURG-127, Products for Wound Healing and Soft Tissue Grafting: Medically Necessary Uses

CIGNA-0068, Tissue Engineered Skin Substitutes

AMBETTER-CP.MP.186, Burn Surgery

AMBETTER-CP.MP.185, Skin and Soft Tissue Substitutes for Diabetic Foot Ulcers and Venous Leg Ulcers

BCBSIL-SUR704.012, Bioengineered Skin and Soft Tissue Substitutes

BCBSMT-SUR704.012, Bioengineered Skin and Soft Tissue Substitutes

BCBSNM-SUR704.012, Bioengineered Skin and Soft Tissue Substitutes

BCBSOK-SUR704.012, Bioengineered Skin and Soft Tissue Substitutes

REGENCE-MED170, Bioengineered Skin and Soft Tissue Substitutes and Amniotic Products

Have a follow-up question?

Ask Backwork about documentation requirements, denial risks, or coverage in your state.

Ask Backwork about Q4105 Sign up free

Q4105, Integra dermal regeneration template (drt) or integra omnigraft dermal