HCPCS Q4111 is officially defined as "Gammagraft, per square centimeter (add-on, list separately in addition to primary procedure)." HCPCS Q4111 is referenced in 13 tracked payer policy changes from Sentara Health Plans, Arkansas Medicaid, and 4 other payers. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for HCPCS Q4111 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.
Starting January 1, 2027, Sentara Health Plans will require prior authorization for a long list of codes on Virginia commercial plans, including self-funded (ASO) plans, and for code 88380 on commercial, Medicaid and Medicare products, plus code 22860 on Medicare products. Sentara will also stop covering a separate list of codes on Virginia commercial and self-funded plans.
Effective August 21, 2026, Arkansas Medicaid now requires prior authorization for nine skin substitute procedure codes across ASC, physician, podiatrist, and prosthetics providers due to fraud and abuse concerns flagged by HHS-OIG. Additionally, reimbursement for skin substitute codes will be bundled into primary surgery codes for most provider types, eliminating separate payment for these materials.
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.
The Arkansas Department of Human Services will require prior authorization for the skin substitute procedures listed in the notice, after the HHS Office of Inspector General flagged skin substitutes as a major area for fraud, waste and abuse. The listed HCPCS codes require prior authorization for dates of service beginning 6/1/2026, and each listed code carries modifier SG. A prior authorization may be requested through AFMC using process type 112 (Other Medical Service).
Health Net California is updating prior authorization requirements effective December 1, 2025, removing PA requirements for many DME items, prosthetics, sleep studies, varicose vein treatments, and therapy services while maintaining PA requirements for non-emergency air transport, hysterectomies, and skin substitutes. These changes aim to reduce administrative burden and streamline approval processes.
Health Net updated multiple medical policies in Q4 2020, affecting prior authorization requirements, coverage criteria, and billing codes across numerous specialties including oxygen therapy, allergy testing, bariatric surgery, wound care, and various diagnostic procedures.
Health Net updated multiple medical policies in Q4 2020, affecting prior authorization requirements, coverage criteria, and billing codes across numerous specialties including oxygen therapy, allergy testing, bariatric surgery, and wound care. Most changes involve revised medical necessity criteria and updated CPT/ICD-10 codes that require immediate attention for proper billing and authorization processes.
CalViva Health updated multiple medical policies for Q4 2020 affecting prior authorization requirements, coverage criteria, and billing codes across numerous specialties. Key changes include revised oxygen therapy criteria, new ambulatory surgery center redirection requirements, updated bariatric surgery protocols, and modified coverage for various diagnostic and therapeutic services.
Michigan Medicaid has revised its policy for skin and tissue substitutes, effective June 5, 2026. Coverage is limited to specific diabetic foot ulcers and chronic venous leg ulcers over 4 weeks duration when used with comprehensive standard wound therapy, with strict documentation requirements for all criteria.
South Carolina Medicaid has established new coverage criteria for skin and tissue substitutes, limiting coverage to diabetic foot ulcers and chronic venous leg ulcers that meet specific duration and wound therapy requirements. All other indications for these products are considered not medically necessary.
New Medicaid policy in Illinois establishes coverage criteria for skin and tissue substitutes for diabetic foot ulcers and chronic venous leg ulcers when specific medical conditions are met. The policy lists covered HCPCS codes and requires comprehensive wound care protocols including standard therapies, infection management, and appropriate clinical assessments.
Molina Healthcare of New York is implementing new prior authorization requirements for transplant/gene therapy drugs and skin substitutes effective October 1, 2025, while removing prior auth requirements for certain ASC procedures (33904) unless performed out-of-network.
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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