Skin Substitute Updates

Date: 10/01/21

Effective November 1, 2021, Arizona Complete Health-Complete Care Plan will update skin substitute prior authorization requirements to align with the AHCCCS preferred products. Non-preferred products will require authorization for all providers. Preferred products with their own specific code will not require an authorization for in-network providers.

As a reminder, failure to obtain prior authorization may result in claim(s) denial.

Providers are encouraged to utilize Arizona Complete Health’s online Pre-Auth Check Tool, located in the For Providers section of our website. See www.azcompletehealth.com for the latest prior authorization requirements for all procedure codes.

Please view the table on the next two pages for details on products, procedure codes, and prior auth requirements.

ADDITIONAL INFORMATION

Providers are encouraged to access Arizona Complete Health’s online secure provider portal at provider.azcompletehealth.com/ for real-time information, including eligibility verification, claims submissions/status, prior authorizations submissions/status, plan summaries, and more.

If you have questions regarding the information contained in this update or need your assigned Provider Engagement Specialist contact information, please email AzchProviderEngagement@azcompletehealth.com.

Product Name	Preferred Status	PA Required	Skin Substitute Type	Manufacturer	FDA Clearance Pathway
ALLOPATCH PLIABLE THIN	Preferred	No PA for PAR Providers	Cellular/dermal replacement from human placental membrane	MTF Biologics	PHS Section 361 Product
AMNIOBAND MEMBRANE	Preferred	No PA for PAR Providers	Allograft Placental Matrix - a fresh amniotic membrane aseptically processed and hypothermically preserved.	MTF Biologics	PHS Section 361 Product
AMNIOBAND MEMBRANE PARTICULATE	Preferred	No PA for PAR Providers	Allograft Placental Matrix - a fresh amniotic membrane aseptically processed and hypothermically preserved.	MTF Biologics	PHS Section 361 Product
AMNIOEXCEL / AMNIOEXCEL PLUS	Preferred	No PA for PAR Providers	Acellular Dermal- dehydrated human amnion-derived tissue allograft with intact extracellular matrix	Integra LifeScience	PHS Section 361 Product
APPLIGRAF	Preferred	No PA for PAR Providers	Cellular/epidermal and dermal replacement from combined human and animal sources	Organogenesis	PMA Product
CYTAL 1, 2, 3 & 6 LAYER	Preferred	No PA for PAR Providers	Acellular/Dermal replacement from animal tissue source - is comprised of porcine urinary bladder matrix with an intact epithelial basement membrane	Integra LifeScience	510(k) Product
DERMGRAFT	Preferred	No PA for PAR Providers	Cellular/dermal replacement from combined natural and synthetic materials	Organogenesis	PMA Product
KERECIS	Preferred	PA for all providers due to unassigned J-code	Acellular/Dermal replacement from animal tissue source - Fish dermal matrix composed of fish collagen	KERECIS	510(k) Product
OMNIGRAFT	Preferred	No PA for PAR Providers	Bilayer matrix epidermal layer and collagen/chondroitin-6-sulfate matrix promoting dermal regeneration	Integra LifeScience	PMA Product
PRIMATRIX	Preferred	No PA for PAR Providers	Acellular/Dermal replacement from animal tissue source - is derived from fetal bovine dermis.	Integra LifeScience	510(k) Product
PRIMATRIX AG	Preferred	No PA for PAR Providers	Acellular/Dermal replacement from animal tissue source - is derived from fetal bovine dermis.	Integra LifeScience	510(k) Product

PRIMATRIX AG FENESTRATED	Preferred	No PA for PAR Providers	Acellular/Dermal replacement from animal tissue source - is derived from fetal bovine dermis.	Integra LifeScience	510(k) Product
PRIMATRIX AG MESHED	Preferred	No PA for PAR Providers	Acellular/Dermal replacement from animal tissue source - is derived from fetal bovine dermis.	Integra LifeScience	510(k) Product
PRIMATRIX FENESTRATED	Preferred	No PA for PAR Providers	Acellular/Dermal replacement from animal tissue source - is derived from fetal bovine dermis.	Integra LifeScience	510(k) Product
PRIMATRIX MESHED	Preferred	No PA for PAR Providers	Acellular/Dermal replacement from animal tissue source - is derived from fetal bovine dermis.	Integra LifeScience	510(k) Product
PURAPLY XT	Preferred	No PA for PAR Providers	Porcine intestinal collagen	Organogenesis	510(k) Product
SOMAGEN MESHED THIN	Preferred	No PA for PAR Providers	Allograft Dermal Matrix	MTF Biologics	PHS Section 361 Product
THERASKIN	Preferred	No PA for PAR Providers	Biologically active cryopreserved human skin allograft with both epidermis and dermis layers	Soluble Systems LLC	PHS Section 361 Product
AFFINITY	Non-Preferred	PA for all providers	Human Amniotic Allograft	Organogenesis	PHS Section 361 Product
EPIFIX / EPIFEX MESH	Non-Preferred	PA for all providers	Acellular Dermal -dehydrated amniotic products	MIMEDX GROUP, INC	PHS Section 361 Product
GRAFIX PL PRIME / GRAFIX PRIME	Non-Preferred	PA for all providers	Cellular/dermal replacement from human placental membrane	SMITH+NEPHEW	PHS Section 361 Product
LENEVA	Non-Preferred	PA for all providers	Allograft Placental Matrix	MTF Biologics	PHS Section 361 Product
Oasis® Wound Matrix Fenestrated	Non-Preferred	PA for all providers	Porcine intestinal collagen - are naturally derived scaffolds of ECM, composed of porcine small intestinal submucosa	SMITH+NEPHEW	510(k) Product
EZ DERM	Non-Preferred - Pending AHCCCS review	PA for all providers	Porcine Dermis	Mölnlycke Health Care	510(k) Product