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AMNIOMATRIX® Human Amniotic Suspension Allograft

AMNIOMATRIX® Human Amniotic Suspension Allograft

AMNIOMATRIX® Human Amniotic Suspension Allograft



  • For homologous use only
  • The liquid based suspension is especially suited for wounds where membrane products might not be as effective (i.e. tunneling or deep wounds)
  • Chronic and acute wounds; diabetic ulcers, venous and arterial ulcers, and pressure ulcers
  • Traumatic injuries
  • Burns
  • Surgical wounds


Regulated under PHS 361 [21 CFR 1270 & 1271]: Human cells, tissues, and cellular and tissue-based products. Creates a unified registration and listing system for establishments that manufacture HCT/Ps and establishes donor eligibility, current good tissue practice, and other procedures to prevent the introduction, transmission, and spread of communicable diseases by HCT/Ps. Among other criteria, HCT/Ps are required to be minimally manipulated and intended for homologous use. Homologous use means the repair, reconstruction, replacement, or supplementation of a recipient’s cells or tissues with an HCT/P that performs the same basic function or functions in the recipient as in the donor. [1]  In the case of amniotic membranes, homologous use include serving as a selective barrier, protection and covering of a wound. 

How supplied

25520: AMNIOMATRIX®, 0.50 ml: Q4139
25530: AMNIOMATRIX®, 1.0 ml: Q4139
25540: AMNIOMATRIX®, 2.0 ml: Q4139
25550: AMNIOMATRIX®, 3.0 ml: Q4139


This section currently focuses primarily on Medicare. It may be expanded in the future to include information on private insurers as well. 

Frequency of replacement allowed by Medicare:

Medicare Administrative Contractor (MAC) Frequency of replacement if requirements met
Novitas Solutions, Inc. Not routinely covered
CGS Administrators, LLC Not routinely covered
Palmetto Carrier discretion
First Coast Service Options, Inc. (FCSO)

1 type of product per 12 weeks, fewest repeat applications and amount of product is expected


Wisconsin Physicians Service Insurance Corporation (WPS)

National Government Services, Inc. (NGS)

Carrier discretion

More details on requirements, medical necessity and documentation in specific Medicare Local Coverage Determinations (if available). See section on Coding, Coverage and Reimbursement in topic "Cellular and/or Tissue Products". 

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NOTE: This is a controlled document. This document is not a substitute for proper training, experience, and exercising of professional judgment. While every effort has been made to ensure the accuracy of the contents, neither the authors nor the Wound Reference, Inc. give any guarantee as to the accuracy of the information contained in them nor accept any liability, with respect to loss, damage, injury or expense arising from any such errors or omissions in the contents of the work.
Topic 297 Version 1.0