Does Q4174 require prior authorization?

Yes, Q4174 requires prior authorization (high confidence). At least one active policy explicitly requires prior authorization.

What is the Medicare reimbursement rate for Q4174?

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

Backwork Sign up free

`Q4174`, Palingen or promatrx, 0.36 mg per 0.25 cc

HCPCS/CPT

Prior Authorization

Prior Auth Required

At least one active policy explicitly requires prior authorization (high confidence)

Medicare Pricing

Work RVU

0.00

Facility

N/A

Non-Facility

N/A

Documentation Required

The article provides billing and coding guidance and references LCD L39116; required documentation (e.g., medical records, prior authorization, specific forms) is not specified here and must be obtained from LCD L39116.
Billing, coding, and documentation requirements (e.g., required medical record elements, coding guidance, prior authorization if applicable) are specified in LCD L39139 and accompanying billing guidance; review LCD L39139 for the exact documentation required for claims.
This billing and coding article provides billing and coding guidance for Local Coverage Determination (LCD) L39575 regarding amniotic and placental-derived product injections/applications for musculoskeletal, non-wound indications.
Full coverage, limitation, and documentation criteria are defined in LCD L39575; the source policy text was not provided in this request.
This billing and coding article references Local Coverage Determination LCD L39624 for coverage and documentation requirements for amniotic and placental-derived product injections/applications for musculoskeletal (non-wound) indications; the LCD text was not provided so specific documentation requirements cannot be extracted.
All documentation must be maintained in the patient's medical record and made available to the contractor upon request.

Key Coverage Criteria

No specific clinical indications are provided in this billing and coding article; coverage criteria for amniotic and placental-derived product injections/applications for musculoskeletal non-wound indications are described in Local Coverage Determination L39116.
Coverage for amniotic and placental-derived product injections/applications for musculoskeletal, non-wound indications is determined by Local Coverage Determination L39139; consult LCD L39139 for specific clinical indications and thresholds.
Coverage applies when the amniotic or placental-derived product injection/application meets the reasonable and necessary requirements of Local Coverage Determination L39877.
Amniotic and placental-derived product injections/applications are covered only when they meet the reasonable and necessary clinical requirements specified in LCD L39879 (Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound).
EpiFix or Grafix (GrafixPL, GrafixPRIME, and GrafixPL PRIME) (Non-Injectable) — Proven and medically necessary for treating a diabetic foot ulcer when ALL of the following criteria are met: adequate circulation to the affected extremity as indicated by one or more of the following: pedal pulses palpable or pulses confirmed with doppler examination; ankle-brachial index (ABI) between 0.7 and 1.2; glycated hemoglobin test (HgA1c) < 12% (within the last 90 days); ulcer has failed to demonstrate ade [...]
First-line (standard of care) non‑surgical/conservative treatments for plantar fasciitis including: stretching exercises, ice, activity modification, weight loss in overweight patients, recommendations for appropriate footwear, arch taping, nonsteroidal anti-inflammatory medications, shock‑absorbing shoe inserts or orthoses (prefabricated orthoses are adequate for the majority of patients).

20 Active Policies

CGS-J15-L39575, Amniotic and Placental Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

J15

CGS-J18-L39575, Amniotic and Placental Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

J18

A59434, Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

WPS-J5-L39624, Amniotic and Placental Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

A58893, Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

NGS-J6-L39139, Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

WPS-J8-L39624, Amniotic and Placental Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

FIRST_COAST-L39877, Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

A59764, Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

NORIDIAN-JE-L39116, Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

NORIDIAN-JF-L39116, Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

NOVITAS-JH-L39879, Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

NGS-JK-L39139, Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

NOVITAS-JL-L39879, Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

A59766, Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

A59374, Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

EVICORE-HPLAN-CIGNA-AFCE721BA4F3, Cigna Comprehensive Code List - Effective 03/07/2026

A58865, Billing and Coding: Amniotic and Placental-Derived Product Injections and/or Applications for Musculoskeletal Indications, Non-Wound

CIGNA-0097, Plantar Fasciitis Treatments

UHC-POL-skin-soft-tissue-substitutes, Skin and Soft Tissue Substitutes

Have a follow-up question?

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

Ask Backwork about Q4174 Sign up free

Q4174, Palingen or promatrx, 0.36 mg per 0.25 cc