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Prior Authorization Requirement Update: Skin Substitutes (Effective 10/30/2025)

Effective October 30, 2025, Meridian will require prior authorization for the following codes:

  • Q4173 PALINGEN OR PALINGEN XPLUS
  • Q4204 XWRAP PER SQ CM
  • Q4250 AMNIOAMP-MP PER SQ CM
  • Q4248 DERMACYTE AMNIOTIC MEMBRANE ALLOGRAFT PER SQ CM
  • Q4234 XCELLERATE PER SQ CM
  • Q4205 MEMBRANE GRAFT OR MEMBRANE WRAP PER SQ CM

All policies and procedures are regularly reviewed as part of our commitment to deliver quality, cost-effective care for Meridian members. To check if an authorization is needed, please utilize our Medicaid Pre-Auth Check Tool.

 

Last Updated: 09/18/2025