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Provider Support Service Line: 1-855-250-1539

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12465 Results

Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; each additional 5 cm or less (List separately in addition to code for primary procedure)

Service Code
13133 (CPT) Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; each additional 5 cm or less (List separately in addition to code for primary procedure)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Repair, complex, eyelids, nose, ears and/or lips; 1.1 cm to 2.5 cm

Service Code
13151 (CPT) Repair, complex, eyelids, nose, ears and/or lips; 1.1 cm to 2.5 cm
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Repair, complex, eyelids, nose, ears and/or lips; 2.6 cm to 7.5 cm

Service Code
13152 (CPT) Repair, complex, eyelids, nose, ears and/or lips; 2.6 cm to 7.5 cm
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Repair, complex, eyelids, nose, ears and/or lips; each additional 5 cm or less (List separately in addition to code for primary procedure)

Service Code
13153 (CPT) Repair, complex, eyelids, nose, ears and/or lips; each additional 5 cm or less (List separately in addition to code for primary procedure)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Secondary closure of surgical wound or dehiscence, extensive or complicated

Service Code
13160 (CPT) Secondary closure of surgical wound or dehiscence, extensive or complicated
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Adjacent tissue transfer or rearrangement, trunk; defect 10 sq cm or less

Service Code
14000 (CPT) Adjacent tissue transfer or rearrangement, trunk; defect 10 sq cm or less
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Adjacent tissue transfer or rearrangement, trunk; defect 10.1 sq cm to 30.0 sq cm

Service Code
14001 (CPT) Adjacent tissue transfer or rearrangement, trunk; defect 10.1 sq cm to 30.0 sq cm
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Adjacent tissue transfer or rearrangement, scalp, arms and/or legs; defect 10 sq cm or less

Service Code
14020 (CPT) Adjacent tissue transfer or rearrangement, scalp, arms and/or legs; defect 10 sq cm or less
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Adjacent tissue transfer or rearrangement, scalp, arms and/or legs; defect 10.1 sq cm to 30.0 sq cm

Service Code
14021 (CPT) Adjacent tissue transfer or rearrangement, scalp, arms and/or legs; defect 10.1 sq cm to 30.0 sq cm
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10 sq cm or less

Service Code
14040 (CPT) Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10 sq cm or less
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10.1 sq cm to 30.0 sq cm

Service Code
14041 (CPT) Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10.1 sq cm to 30.0 sq cm
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips; defect 10 sq cm or less

Service Code
14060 (CPT) Adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips; defect 10 sq cm or less
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips; defect 10.1 sq cm to 30.0 sq cm

Service Code
14061 (CPT) Adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips; defect 10.1 sq cm to 30.0 sq cm
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm

Service Code
14301 (CPT) Adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Adjacent tissue transfer or rearrangement, any area; each additional 30.0 sq cm, or part thereof (List separately in addition to code for primary procedure)

Service Code
14302 (CPT) Adjacent tissue transfer or rearrangement, any area; each additional 30.0 sq cm, or part thereof (List separately in addition to code for primary procedure)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Filleted finger or toe flap, including preparation of recipient site

Service Code
14350 (CPT) Filleted finger or toe flap, including preparation of recipient site
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Skin Substitutes

Service Code
15002 (CPT) Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, trunk, arms, legs; first 100 sq cm or 1% of body area of infants and children
Prior Authorization Required
No
Benefit Plan
Medicaid
Age Group
All
Diagnosis Group
Physical Health

Skin substitutes are used to treat chronic wounds, burns, rare skin conditions, trauma, ischemia, or other neurological impairments; over 90 percent of the lesions are related to venous stasis disease and diabetic neuropathy. These products promote the growth of new skin or serve as a temporary cover until other grafts can be placed. The addition of Skin Substitutes, Cellular or Tissue Based Products (CTPs) to certain wounds may afford a healing advantage over dressings and conservative treatments when these options appear insufficient to affect complete healing. There are currently a wide variety of bioengineered products available for soft tissue coverage to affect closure. These products may be derived from human tissue (allogeneic or autologous), non-human tissue (xenogeneic), synthetic sources or a combination of any or all these types of materials. However, without the component of the recipient’s own distinct epithelium and cellular skin elements, permanent skin replacement or coverage by graft cannot be accomplished.

Unit Value

One unit equals 1 square centimeter

Limits

.a. Apligraf® is limited to 176 units within 180 calendar days, with no more than four applications per ulcer.

  • b. GrafixPrime® is limited to one application per calendar week, for a maximum

of 12 weeks per ulcer.

  • c. GrafixCore® is limited to one application per calendar week, for a maximum

of 12 weeks per ulcer.

  • d. Amnioband® is limited to one application per seven calendar days, for a

maximum of 12 weeks per ulcer.

  • e. Dermagraft®is limited to 304 units within 12 weeks, with no more than 8

applications per ulcer.

  • f. Allopatch is limited to one application per seven calendar days for a

maximum of 12 weeks per ulcer.

  • g. TheraSkin® is limited to eight applications per ulcer. Each application is

limited to 80 units per day, to a maximum of 640 units every 12 weeks. Reapplication of TheraSkin® within one week for the same ulcer is not allowed.

Re-application of TheraSkin® is not allowed for the same ulcer if satisfactory and reasonable healing progress is not noted after 12 weeks of therapy.

  • h. Integra® coverage is limited to the application of a quantity of material that

closely approximates the size of the wound. The number of units billed must closely correlate with the wound size. The maximum daily allowable units are 60.

  • i. EpiFix® is limited to ten applications per ulcer; the initial application, then

additional applications may be applied at a minimum of one-week intervals, for up to a maximum of four applications in 12 weeks, when there is evidence of wound healing.

  • j. Kerecis® is limited to one application per calendar week, for a maximum of

12 weeks per ulcer.

For burn treatments, reimbursement for physician services is limited to the application of the product.

Exclusions

Must be billed in conjunction with codes that describe application of the tissue and preparation of the site. Medicaid also does not cover skin substitutes for infected ulcers; wounds or ulcers progressing toward closure with traditional wound care; eschar or necrotic material; ulcers with sinus tracts or tunnels; underlying osteomyelitis; surrounding cellulitis; known hypersensitivity to substitute materials; arterial disease with ABI less than 0.70 or lack of pedal pulses; uncontrolled diabetes; active Charcot's arthropathy of the ulcer extremity; vasculitis; uncontrolled rheumatoid arthritis or rheumatoid ulcers; other uncontrolled collagen vascular diseases; treatment with high-dose corticosteroids or immunosuppressants; or radiation or chemotherapy within the month immediately preceding proposed treatment.

Place of Service

Place of service for Dermagraft® Apligraf®, EpiFix®, TheraSkin®, GrafixCore®, GrafixPrime®, Allopatch®, Amnioband® and Kerecis® is limited to inpatient, outpatient hospital, and office.

Place of service for Integra® and AlloDerm® is limited to inpatient and outpatient hospital.

How to Submit

N/A - No authorization is required

Resources

Skin Substitutes

Service Code
15003 (CPT) Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, trunk, arms, legs; each additional 100 sq cm, or part thereof, or each additio
Prior Authorization Required
No
Benefit Plan
Medicaid
Age Group
All
Diagnosis Group
Physical Health

Skin substitutes are used to treat chronic wounds, burns, rare skin conditions, trauma, ischemia, or other neurological impairments; over 90 percent of the lesions are related to venous stasis disease and diabetic neuropathy. These products promote the growth of new skin or serve as a temporary cover until other grafts can be placed. The addition of Skin Substitutes, Cellular or Tissue Based Products (CTPs) to certain wounds may afford a healing advantage over dressings and conservative treatments when these options appear insufficient to affect complete healing. There are currently a wide variety of bioengineered products available for soft tissue coverage to affect closure. These products may be derived from human tissue (allogeneic or autologous), non-human tissue (xenogeneic), synthetic sources or a combination of any or all these types of materials. However, without the component of the recipient’s own distinct epithelium and cellular skin elements, permanent skin replacement or coverage by graft cannot be accomplished.

Unit Value

One unit equals 1 square centimeter

Limits

.a. Apligraf® is limited to 176 units within 180 calendar days, with no more than four applications per ulcer.

  • b. GrafixPrime® is limited to one application per calendar week, for a maximum

of 12 weeks per ulcer.

  • c. GrafixCore® is limited to one application per calendar week, for a maximum

of 12 weeks per ulcer.

  • d. Amnioband® is limited to one application per seven calendar days, for a

maximum of 12 weeks per ulcer.

  • e. Dermagraft®is limited to 304 units within 12 weeks, with no more than 8

applications per ulcer.

  • f. Allopatch is limited to one application per seven calendar days for a

maximum of 12 weeks per ulcer.

  • g. TheraSkin® is limited to eight applications per ulcer. Each application is

limited to 80 units per day, to a maximum of 640 units every 12 weeks. Reapplication of TheraSkin® within one week for the same ulcer is not allowed.

Re-application of TheraSkin® is not allowed for the same ulcer if satisfactory and reasonable healing progress is not noted after 12 weeks of therapy.

  • h. Integra® coverage is limited to the application of a quantity of material that

closely approximates the size of the wound. The number of units billed must closely correlate with the wound size. The maximum daily allowable units are 60.

  • i. EpiFix® is limited to ten applications per ulcer; the initial application, then

additional applications may be applied at a minimum of one-week intervals, for up to a maximum of four applications in 12 weeks, when there is evidence of wound healing.

  • j. Kerecis® is limited to one application per calendar week, for a maximum of

12 weeks per ulcer.

For burn treatments, reimbursement for physician services is limited to the application of the product.

Exclusions

Must be billed in conjunction with codes that describe application of the tissue and preparation of the site. Medicaid also does not cover skin substitutes for infected ulcers; wounds or ulcers progressing toward closure with traditional wound care; eschar or necrotic material; ulcers with sinus tracts or tunnels; underlying osteomyelitis; surrounding cellulitis; known hypersensitivity to substitute materials; arterial disease with ABI less than 0.70 or lack of pedal pulses; uncontrolled diabetes; active Charcot's arthropathy of the ulcer extremity; vasculitis; uncontrolled rheumatoid arthritis or rheumatoid ulcers; other uncontrolled collagen vascular diseases; treatment with high-dose corticosteroids or immunosuppressants; or radiation or chemotherapy within the month immediately preceding proposed treatment.

Place of Service

Place of service for Dermagraft® Apligraf®, EpiFix®, TheraSkin®, GrafixCore®, GrafixPrime®, Allopatch®, Amnioband® and Kerecis® is limited to inpatient, outpatient hospital, and office.

Place of service for Integra® and AlloDerm® is limited to inpatient and outpatient hospital.

How to Submit

N/A - No authorization is required

Resources

Skin Substitutes

Service Code
15004 (CPT) Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet and/or
Prior Authorization Required
No
Benefit Plan
Medicaid
Age Group
All
Diagnosis Group
Physical Health

Skin substitutes are used to treat chronic wounds, burns, rare skin conditions, trauma, ischemia, or other neurological impairments; over 90 percent of the lesions are related to venous stasis disease and diabetic neuropathy. These products promote the growth of new skin or serve as a temporary cover until other grafts can be placed. The addition of Skin Substitutes, Cellular or Tissue Based Products (CTPs) to certain wounds may afford a healing advantage over dressings and conservative treatments when these options appear insufficient to affect complete healing. There are currently a wide variety of bioengineered products available for soft tissue coverage to affect closure. These products may be derived from human tissue (allogeneic or autologous), non-human tissue (xenogeneic), synthetic sources or a combination of any or all these types of materials. However, without the component of the recipient’s own distinct epithelium and cellular skin elements, permanent skin replacement or coverage by graft cannot be accomplished.

Unit Value

One unit equals 1 square centimeter

Limits

.a. Apligraf® is limited to 176 units within 180 calendar days, with no more than four applications per ulcer.

  • b. GrafixPrime® is limited to one application per calendar week, for a maximum

of 12 weeks per ulcer.

  • c. GrafixCore® is limited to one application per calendar week, for a maximum

of 12 weeks per ulcer.

  • d. Amnioband® is limited to one application per seven calendar days, for a

maximum of 12 weeks per ulcer.

  • e. Dermagraft®is limited to 304 units within 12 weeks, with no more than 8

applications per ulcer.

  • f. Allopatch is limited to one application per seven calendar days for a

maximum of 12 weeks per ulcer.

  • g. TheraSkin® is limited to eight applications per ulcer. Each application is

limited to 80 units per day, to a maximum of 640 units every 12 weeks. Reapplication of TheraSkin® within one week for the same ulcer is not allowed.

Re-application of TheraSkin® is not allowed for the same ulcer if satisfactory and reasonable healing progress is not noted after 12 weeks of therapy.

  • h. Integra® coverage is limited to the application of a quantity of material that

closely approximates the size of the wound. The number of units billed must closely correlate with the wound size. The maximum daily allowable units are 60.

  • i. EpiFix® is limited to ten applications per ulcer; the initial application, then

additional applications may be applied at a minimum of one-week intervals, for up to a maximum of four applications in 12 weeks, when there is evidence of wound healing.

  • j. Kerecis® is limited to one application per calendar week, for a maximum of

12 weeks per ulcer.

For burn treatments, reimbursement for physician services is limited to the application of the product.

Exclusions

Must be billed in conjunction with codes that describe application of the tissue and preparation of the site. Medicaid also does not cover skin substitutes for infected ulcers; wounds or ulcers progressing toward closure with traditional wound care; eschar or necrotic material; ulcers with sinus tracts or tunnels; underlying osteomyelitis; surrounding cellulitis; known hypersensitivity to substitute materials; arterial disease with ABI less than 0.70 or lack of pedal pulses; uncontrolled diabetes; active Charcot's arthropathy of the ulcer extremity; vasculitis; uncontrolled rheumatoid arthritis or rheumatoid ulcers; other uncontrolled collagen vascular diseases; treatment with high-dose corticosteroids or immunosuppressants; or radiation or chemotherapy within the month immediately preceding proposed treatment.

Place of Service

Place of service for Dermagraft® Apligraf®, EpiFix®, TheraSkin®, GrafixCore®, GrafixPrime®, Allopatch®, Amnioband® and Kerecis® is limited to inpatient, outpatient hospital, and office.

Place of service for Integra® and AlloDerm® is limited to inpatient and outpatient hospital.

How to Submit

N/A - No authorization is required

Resources

Skin Substitutes

Service Code
15005 (CPT) Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet and/or
Prior Authorization Required
No
Benefit Plan
Medicaid
Age Group
All
Diagnosis Group
Physical Health

Skin substitutes are used to treat chronic wounds, burns, rare skin conditions, trauma, ischemia, or other neurological impairments; over 90 percent of the lesions are related to venous stasis disease and diabetic neuropathy. These products promote the growth of new skin or serve as a temporary cover until other grafts can be placed. The addition of Skin Substitutes, Cellular or Tissue Based Products (CTPs) to certain wounds may afford a healing advantage over dressings and conservative treatments when these options appear insufficient to affect complete healing. There are currently a wide variety of bioengineered products available for soft tissue coverage to affect closure. These products may be derived from human tissue (allogeneic or autologous), non-human tissue (xenogeneic), synthetic sources or a combination of any or all these types of materials. However, without the component of the recipient’s own distinct epithelium and cellular skin elements, permanent skin replacement or coverage by graft cannot be accomplished.

Unit Value

One unit equals 1 square centimeter

Limits

.a. Apligraf® is limited to 176 units within 180 calendar days, with no more than four applications per ulcer.

  • b. GrafixPrime® is limited to one application per calendar week, for a maximum

of 12 weeks per ulcer.

  • c. GrafixCore® is limited to one application per calendar week, for a maximum

of 12 weeks per ulcer.

  • d. Amnioband® is limited to one application per seven calendar days, for a

maximum of 12 weeks per ulcer.

  • e. Dermagraft®is limited to 304 units within 12 weeks, with no more than 8

applications per ulcer.

  • f. Allopatch is limited to one application per seven calendar days for a

maximum of 12 weeks per ulcer.

  • g. TheraSkin® is limited to eight applications per ulcer. Each application is

limited to 80 units per day, to a maximum of 640 units every 12 weeks. Reapplication of TheraSkin® within one week for the same ulcer is not allowed.

Re-application of TheraSkin® is not allowed for the same ulcer if satisfactory and reasonable healing progress is not noted after 12 weeks of therapy.

  • h. Integra® coverage is limited to the application of a quantity of material that

closely approximates the size of the wound. The number of units billed must closely correlate with the wound size. The maximum daily allowable units are 60.

  • i. EpiFix® is limited to ten applications per ulcer; the initial application, then

additional applications may be applied at a minimum of one-week intervals, for up to a maximum of four applications in 12 weeks, when there is evidence of wound healing.

  • j. Kerecis® is limited to one application per calendar week, for a maximum of

12 weeks per ulcer.

For burn treatments, reimbursement for physician services is limited to the application of the product.

Exclusions

Must be billed in conjunction with codes that describe application of the tissue and preparation of the site. Medicaid also does not cover skin substitutes for infected ulcers; wounds or ulcers progressing toward closure with traditional wound care; eschar or necrotic material; ulcers with sinus tracts or tunnels; underlying osteomyelitis; surrounding cellulitis; known hypersensitivity to substitute materials; arterial disease with ABI less than 0.70 or lack of pedal pulses; uncontrolled diabetes; active Charcot's arthropathy of the ulcer extremity; vasculitis; uncontrolled rheumatoid arthritis or rheumatoid ulcers; other uncontrolled collagen vascular diseases; treatment with high-dose corticosteroids or immunosuppressants; or radiation or chemotherapy within the month immediately preceding proposed treatment.

Place of Service

Place of service for Dermagraft® Apligraf®, EpiFix®, TheraSkin®, GrafixCore®, GrafixPrime®, Allopatch®, Amnioband® and Kerecis® is limited to inpatient, outpatient hospital, and office.

Place of service for Integra® and AlloDerm® is limited to inpatient and outpatient hospital.

How to Submit

N/A - No authorization is required

Resources