HCPCS Q4255 is officially defined as "Reguard, for topical use only, per square centimeter (add-on, list separately in addition to primary procedure)." HCPCS Q4255 is referenced in 3 tracked payer policy changes from Sentara Health Plans, Aetna, and 1 other payer. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for HCPCS Q4255 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.
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.
Effective October 1, 2020, Prescription Digital Therapeutics for Substance Use Disorder were considered investigational, and Intraoperative Neurophysiologic Monitoring added train of four monitoring as part of intraoperative monitoring that is not separately payable. Generic dimethyl fumarate was added as a first-line treatment for relapsing forms of multiple sclerosis, and Rituxan and Ruxience criteria for neuromyelitis optica spectrum disorder now require a confirmed diagnosis and no longer require a trial of a standard immunosuppressive drug. Coding updates added medical necessity and prior authorization review for HCPCS J9041, J9047, J0725, J3355, A9606, J9043, J3032, J3241, J9227 and J1632, required investigative review for Q4249, Q4250, Q4254, Q4255 and K1007, and made molecular genetic testing codes subject to AIM Specialty Health review with prior authorization.
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