News
Ambetter of North Carolina Inc. is notifying providers of an update to the policy regarding prior authorizations of Skin and Soft Tissue Substitutes for Ambetter Health members.
Date: 07/15/25
Effective September 15, 2025, Clinical Policy: Skin and Soft Tissue Substitutes for Chronic Wounds (CP.MP.185) will require all codes listed within to be reviewed for prior authorization. This policy outlines the review process and clinical rationale for using various types of substitutes available within the healthcare services market.
For the complete Skin and Soft Tissue Substitute Policy, please visit Ambetter Health’s Clinical policy updates page. This policy was reviewed with changes made and will be effective September 1, 2025 as communicated in our June Provider Newsletter.
All policies and procedures are regularly reviewed as part of our commitment to delivering quality, cost-effective care for Ambetter Health members. Please contact your health plans provider engagement team for additional information and questions related to this policy update.
Thank you for your partnership and commitment to improving the health of our communities, one person at a time.
Service codes now requiring PA effective 9/15/25:
C9358 | Dermal substitute, native, nondenatured collagen, fetal bovine origin (SurgiMend Collagen Matrix), per 0.5 sq cm |
C9360 | Dermal substitute, native, nondenatured collagen, neonatal bovine origin (SurgiMend Collagen Matrix), per 0.5 sq cm |
C9363 | Skin substitute (Integra Meshed Bilayer Wound Matrix), per sq cm |
C9364 | Porcine implant, Permacol, per sq cm |
Q4100 | Skin substitute, not otherwise specified |
Q4101 | Apligraf, per sq cm |
Q4102 | Oasis wound matrix, per sq cm |
Q4103 | Oasis burn matrix, per sq cm |
Q4104 | Integra bilayer matrix wound dressing (BMWD), per sq cm |
Q4105 | Integra dermal regeneration template (DRT) or Integra Omnigraft dermal regeneration matrix, per sq cm |
Q4106 | Dermagraft, per sq cm |
Q4107 | Graftjacket, per sq cm |
Q4108 | Integra matrix, per sq cm |
Q4110 | PriMatrix, per sq cm |
Q4112 | Cymetra, injectable, 1 cc |
Q4113 | GRAFTJACKET XPRESS, injectable, 1 cc |
Q4115 | Alloskin, per sq cm |
Q4116 | AlloDerm, per sq cm |
Q4117 | Hyalomatrix, per sq cm |
Q4118 | Matristem micromatrix, 1mg |
Q4121 | TheraSkin, per sq cm |
Q4122 | DermACELL, Dermacell AWM or DermACELL AWM Porous, per sq cm |
Q4123 | AlloSkin RT, per sq cm |
Q4124 | Oasis ultra tri-layer wound matrix, per sq cm |
Q4125 | ArthroFlex, per sq cm |
Q4126 | MemoDerm, DermaSpan, TranZgraft or Integuply, per sq cm |
Q4127 | Talymed, per sq cm |
Q4128 | FlexHD, or AllopatchHD, per sq cm |
Q4132 | Grafix Core and GrafixPL Core, per sq cm |
Q4133 | Grafix PRIME, GrafixPL PRIME, Stravix and StravixPL, per sq cm |
Q4134 | Hmatrix, per sq cm |
Q4135 | Mediskin, per sq cm |
Q4136 | E Z Derm, per sq cm |
Q4138 | BioDFence DryFlex, per sq cm |
Q4140 | BioDFence, per sq cm |
Q4141 | AlloSkin AC, per sq cm |
Q4142 | XCM biologic tissue matrix, per sq cm |
Q4143 | Repriza, per sq cm |
Q4145 | EpiFix, injectable, 1 mg |
Q4146 | TENSIX, per sq cm |
Q4147 | Architect, Architect PX, or Architect FX, extracellular matrix, per sq cm |
Q4148 | Neox Cord 1K, Neox Cord RT, or Clarix Cord 1K, per sq cm |
Q4149 | Excellagen, 0.1 cc |
Q4150 | AlloWrap DS or dry, per sq cm |
Q4151 | AmnioBand or Guardian, per sq cm |
Q4152 | DermaPure, per sq cm |
Q4153 | Dermavest and Plurivest, per sq cm |
Q4154 | Biovance, per sq cm |
Q4155 | Neox Flo or Clarix Flo 1 mg |
Q4156 | Neox 100 or Clarix 100, per sq cm |
Q4157 | Revitalon, per sq cm |
Q4158 | Kerecis Omega3, per sq cm |
Q4159 | Affinity, per sq cm |
Q4160 | Nushield, per sq cm |
Q4161 | Bio-connekt wound matrix, per sq cm |
Q4162 | WoundEx Flow, BioSkin Flow, 0.5 cc |
Q4163 | Woundex, bioskin, per sq cm |
Q4164 | Helicoll, per sq cm |
Q4165 | Keramatrix or Kerasorb, per sq cm |
Q4166 | Cytal, per square centimeter |
Q4167 | Truskin, per sq cm |
Q4168 | AmnioBand, 1 mg |
Q4169 | Artacent wound, per sq cm |
Q4170 | Cygnus, per sq cm |
Q4171 | Interfyl, 1 mg |
Q4173 | Palingen or Palingen Xplus, per sq cm |
Q4174 | PalinGen or ProMatrX, 0.36 mg per 0.25 cc |
Q4175 | Miroderm, per sq cm |
Q4176 | Neopatch or therion, per sq cm |
Q4177 | FlowerAmnioFlo, 0.1 cc |
Q4178 | FlowerAmnioPatch, per sq cm |
Q4179 | FlowerDerm, per sq cm |
Q4180 | Revita, per sq cm |
Q4181 | Amnio Wound, per sq cm |
Q4182 | Transcyte, per sq cm |
Q4183 | Surgigraft, per sq cm |
Q4184 | Cellesta or Cellesta Duo, per sq cm |
Q4185 | Cellesta Flowable Amnion (25 mg per cc); per 0.5 cc |
Q4186 | Epifix, per sq cm |
Q4187 | Epicord, per sq cm |
Q4188 | AmnioArmor, per sq cm |
Q4189 | Artacent AC, 1 mg |
Q4190 | Artacent AC, per sq cm |
Q4191 | Restorigin, per sq cm |
Q4192 | Restorigin, 1 cc |
Q4193 | Coll-e-Derm, per sq cm |
Q4194 | Novachor, per sq cm |
Q4195 | PuraPly, per square cm |
Q4196 | PuraPly AM , per square cm |
Q4197 | Puraply XT, per square cm |
Q4198 | Genesis Amniotic Membrane, per sq cm |
Q4200 | SkinTE, per sq cm |
Q4201 | Matrion, per sq cm |
Q4202 | Keroxx (2.5 g/cc), 1 cc |
Q4203 | Derma-Gide, per sq cm |
Q4204 | XWRAP, per sq cm |
Q4227 | AmnioCore TM, per sq cm |
Q4229 | Cogenex Amniotic Membrane, per sq cm |
Q4230 | Cogenex Flowable Amnion, per 0.5 cc |
Q4231 | Corplex P, per cc |
Q4232 | Corplex, per sq cm |
Q4233 | SurFactor or NuDyn, per 0.5 cc |
Q4234 | Xcellerate, per sq cm |
Q4235 | AMNIOREPAIR or AltiPly, per sq cm |
Q4237 | Cryo-Cord, per sq cm |
Q4238 | Derm-Maxx, per sq cm |
Q4239 | Amnio-Maxx or Amnio-Maxx Lite, per sq cm |
Q4240 | CoreCyte, for topical use only, per 0.5 cc |
Q4241 | PolyCyte, for topical use only, per 0.5 cc |
Q4242 | AmnioCyte Plus, per 0.5 cc |
Q4245 | AmnioText, per cc |
Q4246 | CoreText or ProText, per cc |
Q4247 | Amniotext patch, per sq cm |
Q4248 | Dermacyte Amniotic Membrane Allograft, per sq cm |
Q4249 | AMNIPLY, for topical use only, per sq cm |
Q4250 | AmnioAmp-MP, per sq cm |
Q4251 | Vim, per sq cm |
Q4252 | Vendaje, per sq cm |
Q4253 | Zenith amniotic membrane, per sq cm |
Q4254 | Novafix, per sq cm |
Q4255 | REGUaRD, for topical use only, per sq cm |