Based on Medical Necessity - PO Only
Policy No.
No Policy
States
Grafix Core Q4132
Covered Based on Medical Necessity – DFU/VLU/DLEU; Other Wounds HOPD Only
PA Required
Grafix PL/Prime Q4133
Covered Based on Medical Necessity – DFU/VLU/DLEU; Other Wounds HOPD Only
PA Required