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