Preferred skin substitute products (coverage and prior authorization)
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Defines Health Choice Arizona's preferred skin substitute products list and prior authorization expectations for providers; applies to providers submitting claims for skin substitute products under the Health Choice Arizona / Blue Cross Blue Shield - Arizona arrangement.
No material clinical or coverage changes in this revision.
Coverage Criteria
Coverage for preferred products
Covered when ALL of the following are met
Preferred products require prior authorization; see Health Choice prior authorization guidelines
Coverage for non-preferred products (exception basis)
Covered when ALL of the following are met
All skin substitute products not listed as preferred will be considered non-preferred effective 10/1/2021; non-preferred requests must include supporting documentation
All skin substitute products not included in the list of preferred products will be designated non-preferred effective 10/01/2021. The preferred product list (effective 10/1/2021) and examples of included HCPCS/Q‑codes are published in the notice of preferred skin substitute products.
Use of a non-preferred skin substitute product may result in claim denial unless the provider submits supporting documentation explaining why a preferred product is not an appropriate option and obtains prior authorization per Health Choice guidelines.
Coding — Preferred Codes
| Q4100 | Skin substitute Not Otherwise Specified (for SomaGen only) |
| Q4101 | Apligraf, per sq cm |
| Q4105 | Integra dermal regeneration template (DRT) or Integra Omnigraft dermal regeneration matrix, per sq cm |
| Q4106 | Dermagraft, per sq cm |
| Q4110 | PriMatrix, per sq cm (PriMatrix AG and variants) |
| Q4121 | TheraSkin, per sq cm |
| Q4128 | FlexHD, AllopatchHD, or Matrix HD, per sq cm |
| Q4137 | AmnioExcel, AmnioExcel Plus or BioDExcel, per sq |
| Q4151 | AmnioBand or Guardian, per sq cm |
| Q4158 | Kerecis Omega3, per sq cm |
Provider Actions and Requirements
Prior authorization required for all listed products
All listed skin substitute products require prior authorization. Requests for non-preferred products also require supporting documentation explaining why preferred products are not an option.
- Obtain Health Choice Arizona prior authorization before submitting claims for any listed skin substitute product.
- For non-preferred products, include documentation that explains why a preferred product is not an option.
Follow HCA prior authorization submission process
Providers must follow the Health Choice Arizona prior authorization process and submit requests using the PA Guidelines and PA Grids available on the Health Choice websites.
- Use the Health Choice Arizona Provider tab PA Guidelines and PA Grids to determine submission requirements.
- Links: HCA Provider Tab -> PA Guidelines; HCP Provider Tab -> Provider Information.
Include justification for non-preferred product requests
Documentation supporting why a preferred product is not an option must accompany requests for non-preferred products.
- Include clinical justification and any relevant prior attempts with preferred products when submitting a non-preferred product request.
Risk of denial for non-preferred products without PA and justification
Use of a non-preferred skin substitute product will require documentation justifying why a preferred product is not an option; non-preferred products may be denied without that documentation and prior authorization.
- Effective 10/1/2021, all skin substitute products not listed as preferred will be considered non-preferred.
- Non-preferred product requests are at risk of denial if prior authorization and supporting documentation are not provided.
Definitions
Background
This notice identifies which skin substitute products Health Choice Arizona designates as preferred for coverage effective 10/01/2021. The notice specifies the covered HCPCS/Q‑codes and trade names (for example, Q4101 Apligraf; Q4106 Dermagraft; Q4121 TheraSkin; Q4158 Kerecis Omega3; etc.). Any skin substitute products not on that published list are considered non-preferred beginning 10/01/2021 and require supporting documentation and prior authorization for coverage consideration.
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