ModifiedUnitedHealthcarePolicy CS153ID.C

Skin and Soft Tissue Substitutes (for Idaho Only)

State-specific UnitedHealthcare medical policy governing coverage guidance for skin and soft tissue substitute products for members in Idaho, including Idaho Medicaid Plus plans; refers to Idaho Medicaid Provider Handbook Chapter 4.36 for medical necessity criteria and lists applicable HCPCS codes for reference.

Policy Summary

PayerUnitedHealthcare

PolicySkin and Soft Tissue Substitutes (for Idaho Only)

Policy CodePolicy CS153ID.C

Change TypeHCPCS code additions; supporting info archived prior version

Effective DateFeb 1, 2026

Next Review Date

Key ActionWhen determining coverage for Idaho members, refer to Idaho Medicaid Provider Handbook, Medical Services, Chapter 4.36 for medical necessity criteria.

POLICY UPDATE CHANGES

Added multiple HCPCS codes to Applicable Codes (02/01/2026).

Archived prior policy version CS153ID.B; updated Idaho-specific policy version CS153ID.C (02/01/2026).

1State restricted policy (Idaho only)

100+HCPCS codes listed

YesMaterial change?

Coverage Summary

This policy is a state-specific UnitedHealthcare medical policy titled Skin and Soft Tissue Substitutes (Idaho only) (Policy Number CS153ID.C), governing coverage guidance for skin and soft tissue substitute products for members in Idaho, including Idaho Medicaid Plus plans.

Coverage guidance is informational in stance and refers providers to the Idaho Medicaid Provider Handbook (Medical Services, Chapter 4.36: Skin Substitute Products) for the medical necessity clinical coverage criteria that determine coverage decisions.

The policy is effective February 1, 2026. A material change noted 02/01/2026 added multiple HCPCS codes to the Applicable Codes list and archived the prior version CS153ID.B.

Medical-Necessity Criteria

State-Specific Criteria / Medical Necessity

Refer to Idaho Medicaid Provider Handbook, Medical Services, Chapter 4.36: Skin Substitute Products for medical necessity clinical coverage criteria.

ALL of the following

Policy applies only to the state of Idaho, including Idaho Medicaid Plus plans
Medical necessity criteria are governed by the Idaho Medicaid Provider Handbook (Chapter 4.36) and must be used to determine coverage

Applicable Codes (HCPCS / CPT)

Applicable HCPCS / CPT Codes (reference list)HCPCS

A2001	InnovaMatrix AC, per sq cm
A2002	Mirragen Advanced Wound Matrix, per sq cm
A2004	XCelliStem, 1mg
A2005	Microlyte Matrix, per sq cm
A2006	NovoSorb SynPath dermal matrix, per sq cm
A2007	Restrata, per sq cm
A2008	TheraGenesis, per sq cm
A2009	Symphony, per sq cm
A2010	Apis, per sq cm
A2011	Supra SDRM, per sq cm

1–10 of 279

1/28

Provider Actions & Billing Guidance

Documentation Required

Follow Idaho Medicaid handbook for medical necessity

When determining coverage for skin and soft tissue substitutes for Idaho members, providers must refer to Idaho Medicaid Provider Handbook, Medical Services, Chapter 4.36; coverage decisions depend on that handbook's medical necessity criteria.

Billing Rule

HCPCS code reporting

Report skin substitute products using the applicable HCPCS codes listed in this policy; inclusion of a code is for reference only and does not guarantee coverage or reimbursement—federal, state or contractual requirements govern benefit coverage.

See code table / list for full HCPCS codes added 02/01/2026 (example added codes: Q4368, Q4369, Q4370, Q4371, Q4372, Q4373, Q4375, Q4376, Q4377, Q4378, Q4379, Q4380, Q4382)
Full HCPCS/Q- code list also appears in the Applicable Codes section of the policy for reference

Background

UnitedHealthcare provides state-specific guidance for skin and soft tissue substitute products and lists applicable HCPCS/CPT codes for reference; inclusion of a code does not guarantee coverage or reimbursement and federal, state, or contractual requirements govern benefit coverage.

FDA regulatory pathways for skin substitutes are summarized for informational purposes only; FDA clearance or approval alone is not a basis for coverage and the FDA section describes PMA, 510(k), HCT/P (21 CFR 1270 & 1271), HDE, and other pathways.

When determining coverage for Idaho members, providers must refer to the Idaho Medicaid Provider Handbook, Medical Services, Chapter 4.36, because medical necessity determinations are governed by that handbook and by applicable federal, state, or contractual requirements.

Policy history notes a Summary of Changes on 02/01/2026 adding a set of HCPCS codes to Applicable Codes and archiving the previous Idaho-specific policy version.

Definitions: HCT/P — Human Cells, Tissues, and Cellular and Tissue-Based Products regulated under 21 CFR 1270 & 1271 (minimally manipulated human-derived tissue).

Revision History

02/01/2026material_changeLatest

Added HCPCS codes Q4368, Q4369, Q4370, Q4371, Q4372, Q4373, Q4375, Q4376, Q4377, Q4378, Q4379, Q4380, and Q4382 to the Applicable Codes list (Summary of Changes entry effective 02/01/2026).

02/01/2026archival

Archived previous policy version CS153ID.B and published updated Idaho-specific policy version CS153ID.C effective 02/01/2026 (Supporting Information).