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Q4100

PAYER POLICY CHANGES

Q4100 Insurance Policy Changes

HCPCS Q4100 is officially defined as "Skin substitute, not otherwise specified." HCPCS Q4100 is referenced in 10 tracked payer policy changes from Excellus BlueCross BlueShield, Humana, and 5 other payers. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for HCPCS Q4100 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.

Excellus BlueCross BlueShield · Effective Aug 20, 2026High impact
Bioengineered Tissue Products for Wound Treatment and Surgical Interventions 7.01.35
Excellus BlueCross BlueShield medical policy 7.01.35, Bioengineered Tissue Products for Wound Treatment and Surgical Interventions, has a current effective date of August 20, 2026. The 08/20/26 annual review added CPT codes 15011-15018, and the 10/22/26 off-cycle update added HCPCS codes A2041-A2050, G0681-G0684, Q4243, Q4398-Q4429, Q4431-Q4433 and Q4435-Q4440 while removing termed HCPCS codes C5271-C5278, Q4100 and Q4106. Policy intent is unchanged for both updates.
Humana · Effective Aug 12, 2026High impact
Skin and Tissue Substitutes - MEDICAID - KENTUCKY (Revised)
Humana's revised Kentucky Medicaid policy on skin and tissue substitutes lists the only covered uses as diabetic foot ulcers and venous leg ulcers that have lasted more than 4 weeks, when standard wound care criteria are met, and states that prior authorization is required. The policy lists many HCPCS codes for these products as requiring prior authorization for Humana Healthy Horizons members in Kentucky. The source gives an effective date of 08/12/2026, and the code list in the provided text is cut off near the end.
Medical Mutual of Ohio · Effective May 1, 2026High impact
Mutual News April 2026 Newsletter
Under this notice, administrative changes are effective on the date of the notice, material changes are effective 90 days from the date of the notice, and new prior authorizations are effective 30 days from the date of the notice, unless otherwise specified. Effective May 1, 2026, the maximum frequency per day (MFD) policy requires allowable units up to the MFD on one claim line and any additional units on a separate claim line, and new reimbursement policies cover related services and supplies (RP-202603) and replacement codes for CMS status indicator I (RP-202604). Effective with dates of service on or after June 1, 2026, non-clinical disputes and corrected claims must be submitted within 180 days from the date of the original claim determination, and these timelines replace the previous requirements. CPT 43889 is added to the bariatric surgery policy and requires prior authorization effective June 1, 2026. The notice also revises a number of medical policies, including removing the frequency limitation and prior authorization requirement for certain bone mineral density codes.
Independence Blue Cross · Effective Jan 1, 2026High impact
MA11.030i, Reconstructive Breast Surgery
Independence Blue Cross updated CPT/HCPCS coding descriptors and terminology for reconstructive breast surgery materials effective 01/01/2026. Key changes include: Q4130 (Strattice) and Q4116 (AlloDerm) now specified as add-on codes with updated descriptors; Q4100 (generic skin substitute) terminated and replaced by Q4433; and C5271/C5272 (low-cost skin substitute application codes) removed from coverage. Billing teams must update systems to reflect new code terminology and add-on designations to avoid claim denials.
Independence Blue Cross · Effective Jan 1, 2026High impact
11.08.15ad, Reconstructive Breast Surgery and Post-Mastectomy Prostheses
Independence Blue Cross has updated policy 11.08.15ad to 11.08.15ae with CPT/HCPCS code revisions effective 01/01/2026. Two HCPCS codes (Q4130, Q4116) have been reformatted to reflect add-on code status with updated descriptions, one NOC code (Q4100) has been terminated and replaced by Q4433, and two C-codes (C5271, C5272) for low-cost skin substitutes have been removed from coverage. Billing teams must update their systems to reflect these code changes to avoid claim denials.
Humana · Effective Nov 12, 2025High impact
Skin and Tissue Substitutes - MEDICAID - LOUISIANA (New)
Humana Louisiana Medicaid has established a new coverage policy for skin and tissue substitutes (cellular and tissue-based products). The policy defines specific coverage criteria for 12 different skin substitute products including Apligraf, Dermagraft, and Integra products, primarily for treating diabetic foot ulcers, venous leg ulcers, and burn wounds that meet specific duration and severity requirements.
CareSource · Effective Jul 25, 2025High impact
[Ohio] Requirements for Including National Drug Code
Ohio Medicaid now requires National Drug Codes (NDC) to be included in the LIN segment of 837 claims for specific HCPCS and CPT drug codes (B4164-B4240, J0120-J9999, Q0138-Q9999, S0145-S5001, CPT 90281-90399). Notably, Q4100-Q4499 skin substitutes and RSV vaccine codes 90380-90381 are EXCLUDED from NDC requirements. The CTP segment must also be used for J-series, B-series, Q-series, and S-series drug codes.
Humana · Effective Oct 7, 2025Medium impact
Skin and Tissue Substitutes - MEDICAID - KENTUCKY (New)
New Kentucky Medicaid policy establishes coverage criteria for 13 specific skin and tissue substitute products for wound care, burns, and breast reconstruction. The policy defines which HCPCS codes are covered and under what clinical conditions each product can be billed.
Aetna · Identified Aug 17, 2026Medium impact
Mohs Micrographic Surgery (CPB 0383, reviewed 2026-05-28)
Aetna's Clinical Policy Bulletin 0383 considers Mohs micrographic surgery medically necessary for lesions in areas of important tissue preservation (ears, face, feet, hands, genitalia and perianal area), atypical fibroxanthoma, dermatofibrosarcoma protuberans, lesions 2 cm or larger or rapidly growing, lesions in high-recurrence areas, previously irradiated skin, recurrent or incompletely excised malignant lesions, squamous cell carcinomas with high risk of metastasis, superficial melanoma in situ and lentigo maligna in areas of important tissue preservation, tumors with aggressive histologic patterns, and tumors with ill-defined borders. Aetna considers Mohs surgery for all other indications experimental, investigational or unproven, including adenoid cystic carcinoma, nail unit melanoma, pilomatrix carcinoma, vulvar malignancies and deep cutaneous fungal infections. Mohs micrographic surgery requires a single physician to act as both surgeon and pathologist, and the Mohs CPT codes are inappropriate if either role is delegated to another physician who reports those services separately.
Blue Cross & Blue Shield of Mississippi · Identified Jun 20, 2026Medium impact
Bioengineered Skin and Soft Tissue Substitutes
Several listed tissue-engineered skin substitutes may be considered medically necessary for specific uses, including breast reconstruction with listed acellular dermal matrix products, chronic noninfected full-thickness diabetic lower-extremity ulcers, chronic venous insufficiency ulcers that have not adequately responded to a 1-month period of conventional ulcer therapy, dystrophic epidermolysis bullosa, and second- and third-degree burns. All other uses of the listed products, and all other skin and soft tissue substitutes not listed, are considered investigational. Code reference updates dated 07/01/2026, 08/15/2026 and 10/01/2026 add CPT 1045T through 1049T, HCPCS C9353 and C9361, and HCPCS A2046, A2047, A2048 and A2050 as investigational codes.

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REFERENCE DATA

Payers with rules9

Payers requiring prior auth9

CountyCare Health Plan · Effective April 23, 2026
Prior authorization required
CountyCare Prior Authorization Look-Up Tool (All Codes)
Ambetter · Effective December 31, 2025
Prior authorization required
Ambetter from Arizona Complete Health CMS-0057-F prior authorization requirements
Arizona Complete Health · Effective December 31, 2025
Prior authorization required
Arizona Complete Health CMS-0057-F prior authorization requirements

FREQUENTLY ASKED QUESTIONS

Does Ambetter require prior authorization for Q4100?

Ambetter lists Q4100 on Ambetter from Arizona Complete Health CMS-0057-F prior authorization requirements for exchange plans (list dated December 31, 2025). Verify with the payer before scheduling.

Does AmeriHealth Caritas require prior authorization for Q4100?

AmeriHealth Caritas lists Q4100 on AmeriHealth Caritas Louisiana prior authorization service list for medicaid managed plans. Verify with the payer before scheduling.

Does Arizona Complete Health require prior authorization for Q4100?

Arizona Complete Health lists Q4100 on Arizona Complete Health CMS-0057-F prior authorization requirements for medicaid managed plans (list dated December 31, 2025). Verify with the payer before scheduling.

Does BCBS Illinois require prior authorization for Q4100?

BCBS Illinois lists Q4100 on Blue Cross Community Health Plans (Illinois Medicaid) Prior Authorization Code List for medicaid managed plans, with conditions (list dated October 1, 2026). Verify with the payer before scheduling.

Does CalViva Health require prior authorization for Q4100?

CalViva Health lists Q4100 on CalViva Health CMS-0057-F prior authorization requirements for medicaid managed plans (list dated December 31, 2025). Verify with the payer before scheduling.

What insurance policy changes affect HCPCS Q4100?

There are 10 tracked policy changes affecting HCPCS Q4100, including updates from Excellus BlueCross BlueShield, Humana, Medical Mutual of Ohio. Each change may modify coverage criteria, reimbursement rates, or prior-authorization requirements.

Which payers have updated policy for HCPCS Q4100?

Payers that have issued tracked updates for HCPCS Q4100 include: Excellus BlueCross BlueShield, Humana, Medical Mutual of Ohio, Independence Blue Cross, CareSource, Aetna, Blue Cross & Blue Shield of Mississippi.

How do I get notified when HCPCS Q4100 policy changes?

Create a free account at PolicyChanges.app and save a search filtered to HCPCS Q4100. You will get an email when new policy changes reference this code: daily or weekly, your choice, on every plan.

Why do payers change policies for HCPCS Q4100?

Payers revise policies for individual billing codes to align with updated clinical guidelines, CMS rule changes, fraud and abuse prevention measures, or network cost-management goals. Changes can affect medical necessity criteria, place-of-service restrictions, bundling rules, or whether a code requires prior authorization.

See every payer rule for Q4100

Prior authorization lists, coverage criteria, NCCI edits and Medicare coverage articles for Q4100 in one place.

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All billing codes J3590 C9399 J3490 99215 99213 99202

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Bioengineered Tissue Products for Wound Treatment and Surgical Interventions 7.01.35

Skin and Tissue Substitutes - MEDICAID - KENTUCKY (Revised)

Mutual News April 2026 Newsletter

MA11.030i, Reconstructive Breast Surgery

11.08.15ad, Reconstructive Breast Surgery and Post-Mastectomy Prostheses

Skin and Tissue Substitutes - MEDICAID - LOUISIANA (New)

[Ohio] Requirements for Including National Drug Code

Skin and Tissue Substitutes - MEDICAID - KENTUCKY (New)

Mohs Micrographic Surgery (CPB 0383, reviewed 2026-05-28)

Bioengineered Skin and Soft Tissue Substitutes

Prior authorization required

Prior authorization required

Prior authorization required

Does Ambetter require prior authorization for Q4100?

Does AmeriHealth Caritas require prior authorization for Q4100?

Does Arizona Complete Health require prior authorization for Q4100?

Does BCBS Illinois require prior authorization for Q4100?

Does CalViva Health require prior authorization for Q4100?

What insurance policy changes affect HCPCS Q4100?

Which payers have updated policy for HCPCS Q4100?

How do I get notified when HCPCS Q4100 policy changes?

Why do payers change policies for HCPCS Q4100?