Sixty-nine sheets of processed tissue, all placed on chronic wounds, all billed to Medicare Part B in 2024. The cheapest cost $30 a square centimeter. The dearest cost $4,160. Then CMS drew a single line at $127.28.
Under the payment rule that governed skin substitutes through 2025, each product got its own billing code and its own payment limit, derived from the price the manufacturer itself reported. Launch high, and Medicare's allowed amount follows you up. Launch low, and it doesn't.
Every dot below is a real HCPCS code, a real 2024 Medicare payment, and a real wound.
Press the second button. The dots slide left onto the line and drop, because under CMS-1832-F, effective January 1, 2026, nearly every one of these products is paid as an incident-to supply at a single national rate of $127.28 per square centimeter, regardless of brand.
Look at where the field lands. Almost everything was above the line, most of it by an order of magnitude. The handful of dots at the far left — Apligraf at $30, the two Puraply codes at $102 and $108 — sit at or below $127.28 already. They were never the problem, and they are not what grew.
Apligraf, HCPCS Q4101, is a living bilayer skin substitute approved by FDA under a PMA in 1998. It is paid under ASP+6%, and Medicare's allowed amount per square centimeter has been remarkably steady:
National Part B spending on these codes, by service year. The number of distinct products billed is printed above each bar.
| Caveat | Effect |
|---|---|
| Products below $5M in 2024 omitted | 25 codes, 0.2% of spend |
| Non-facility (office) + facility combined | rates differ by setting |
| “Patients” = beneficiaries per code | one person, several codes, counted twice |
| Rows with ≤10 beneficiaries | suppressed by CMS entirely |
| 2025 and 2026 spending | not yet in the public file |
Wolf's reporting is not primarily about the payment rate. It is about the other lever — a Medicare coverage determination that would have restricted which products qualified at all — and the campaign that stopped it. Her account traces $100,000 donations made on a single day in January 2025, a $1M contribution to MAGA Inc., and the withdrawal of the proposed coverage restrictions on December 24, 2025, days before they were to take effect. Meanwhile DOJ sentenced two skin-substitute company owners to 15.5 and 14 years.
The flat rate removes the arbitrage. It does not answer whether these grafts should be placed on these wounds at all — that was the coverage question, and it is still open. A separate Fifth Circuit challenge from wound-care manufacturers is pending.
The build: the transferable move here is not about wound care. It is that a payment methodology which derives a price from the seller's own reported price will be gamed, every time, in every category, and the tell is always the same shape — spending growing an order of magnitude faster than patients. If you are building or buying anything reimbursed that way, plot those two lines against each other before you plot anything else.