Effective February 27, 2026: New Prior Authorization Requirement for Certain New Procedure Codes
Date: 11/21/25
Effective February 27, 2026, Superior HealthPlan will require prior authorization for certain new procedure codes for Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP and Ambetter from Superior HealthPlan members.
Superior ensures medical necessity review criteria is current and appropriate for members and the scope of services provided. As a result, the following procedure code update is effective on February 27, 2026, and is noted below with applicable product line.
Medicaid and CHIP members
DME
Description | Criteria | |
E0658 | SEGMENTAL PNEUMATIC COMP 2 FULL ARMS AND CHEST | Change Healthcare’s InterQual criteria for Pneumatic Compression Devices, proprietary, but available upon request.
|
E0659 | SEG PNEU APPL USE W/PNEU COMP INTG HEAD NCK AND CT |
Orthotics and Prosthetics
Procedure Code | Description | Criteria |
L1007 | SCOLIOSIS ORTHOSIS SAGITTAL-CORONAL CTRL CUSTOM | CP.MP.107 Durable Medical Equipment and Orthotics and Prosthetics Guidelines
For more information visit Superior’s Clinical, Payment & Pharmacy Policies webpage. |
L6034 | PAR HND FNGR AND THMB PROS NOT INCL INSR DESCR L6692 |
Ambetter from Superior HealthPlan members
Prosthetics
Procedure Code | Description | Criteria |
L5657 | ADD LW EXT PROS MAN/AUTO LIMB VOL MGMT ANY MTRLS | CP.MP.107 Durable Medical Equipment and Orthotics and Prosthetics Guidelines
For more information visit Superior’s Clinical, Payment & Pharmacy Policies webpage
|
L6035 | SINGLE PROSTHETIC DIGIT MECH INITIAL ISSUE/REPLC | |
L6036 | PROSTHETIC THUMB MECH INITIAL ISSUE/REPLACEMENT | |
L6038 | ADD SINGLE PROS DIGIT/THUMB MECH ATT MULTIAXIAL | |
L6039 | PASSIVE PROSTHETIC DIGIT/THUMB PROS DIGIT/THUMB |
Chronic Wound Skin and Soft Tissue Substitutes
Procedure Code | Description | Criteria |
A2036 | COHEALYX COLLAGEN DERMAL MATRIX PER SQ CM | CP.MP.185 Skin and Soft Tissue Substitutes for Chronic Wounds For more information visit Superior’s Clinical, Payment & Pharmacy Policies webpage
|
A2037 | G4DERM PLUS PER ML | |
A2038 | MARIGEN PACTO PER SQ CM | |
A2039 | INNOVAMATRIX FD PER SQ CM | |
Q4383 | AXOLOTL GRAFT ULTRA PER SQ CM | |
Q4384 | AXOLOTL DUALGRAFT ULTRA PER SQ CM | |
Q4385 | APOLLO FT PER SQ CM | |
Q4386 | ACESSO TRIFACA PER SQ CM | |
Q4387 | NEOTHELIUM FT PER SQ CM | |
Q4388 | NEOTHELIUM 4L PER SQ CM | |
Q4389 | NEOTHELIUM 4L PLUS PER SQ CM | |
Q4390 | ASCENDION PER SQ CM | |
Q4391 | AMNIOPLAST DOUBLE PER SQ CM | |
Q4392 | GRAFIX DUO PER SQ CM | |
Q4393 | SURGRAFT AC PER SQ CM | |
Q4394 | SURGRAFT ACA PER SQ CM | |
Q4395 | ACELAGRAFT PER SQ CM | |
Q4396 | NATALIN PER SQ CM | |
Q4397 | SUMMIT AAA PER SQ CM |
To review prior authorization requirements, please visit Superior’s Prior Authorization webpage.
For questions or additional information, contact Superior’s Prior Authorization department at 1-800-218-7508.