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Effective July 31, 2026: Clinical Policies

Date: 05/20/26

Superior HealthPlan and Ambetter from Superior HealthPlan has added and updated certain clinical policies to ensure medical necessity review criteria is current and appropriate for members and the scope of services provided. As a result, the following policies are effective on July 31, 2026, at 12:00AM.

Policy

Applicable Products

New Policy Overview or Updated Policy Revisions

Air Ambulance

(CP.MP.175)

Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS) and CHIP

New Policy Overview:

  • Description
  • Policy and Criteria
  • Background
  • Most recent update: Coding and descriptions reviewed

Skin and Soft Tissue Substitutes

(CP.MP.185)

Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter

Policy updates include:

  • Changed policy name to “Skin and Soft Tissue Substitutes”
  • In Notes section, added additional bullet points to refer to MC.CP.MP 185, CP.MP.186, and CP.MP.31, as applicable
  • In policy statements I and II, noted that the medical necessity requirements are “specific to the wound for which the skin substitute/CTP is being requested” and added as the first criterion that the “request indicates the specific wound to which the skin substitute will be applied”
  • Reworded I.D.5 to more clearly require that member/enrollees who smoke participate in smoking cessation therapy
  • In criteria I.E., updated product list for DFUs/VLUs
  • In I.F.6. and II.B.6., deleted code Q4106 was replaced with code Q4431
  • In the Note in I.H. and II.E., removed “16”
  • In II.B., updated product list for DFUs/VLUs
  • Added criteria IV. regarding skin substitute use for burn treatment, with IV.B. thru IV.D. and IV.F. moved from CP.MP.186
  • Added criteria V. regarding skin substitute use for breast reconstruction
  • Added criteria VI. regarding skin substitute use for dystrophic epidermolysis bullosa
  • Added criteria VII. regarding skin substitute use for post-reconstructive surgery of abdominal wall wounds
  • Added criteria VIII. regarding indications considered not medically necessary
  • Added criteria IX. regarding indications of which evidence that does not support
  • Background section updated to include new sections on burns, breast reconstruction, dystrophic epidermolysis, and post-reconstruction surgery of abdominal wall wounds
  • Updated titles of coding tables
  • Coding reviewed and updated
  • Added HCPCS Code Table 1
  • To HCPCS Code Table 1, added codes G0681, G0682, G0683, and G0684. Added Note under HCPCS Code Table 2
  • To HCPCS Code Table 2, added the following: A2012, A2043, A2044, A4100, C1781, C9363, C9399, Q4108, Q4116, Q4122, Q4130, Q4182, Q4431, and Q4433
  • From HCPCS Code Table 2, removed the following: Q4106, Q4110, Q4111, Q4115, Q4117, Q4118, Q4124, Q4137, Q4141, Q4146, Q4148, Q4151, Q4152, Q4154, Q4156, Q4159, Q4160, Q4166, Q4170, Q4175, Q4178, Q4187, Q4188, Q4195, Q4196, Q4197, Q4201, Q4203, Q4236, Q4253, Q4262
  • For HCPCS Code Table 3, added the following codes: A2004, A2008, A2040, A2041, A2042, A2045, A4175, C9250 Q4111 Q4115 Q4117, Q4118, Q4124, Q4137, Q4141, Q4146, Q4148, Q4151, Q4152, Q4154, Q4156, Q4159, Q4160, Q4166, Q4170, Q4175, Q4178, Q4187, Q4195, Q4196, Q4197, Q4201, Q4203, Q4236, Q4253, Q4262, Q4398, Q4399, Q4400, Q4401, Q4402, Q4403, Q4404, Q4405, Q4406, Q4407, Q4408, Q4409, Q4410, Q4411, Q4412, Q4413, Q4414, Q4415, Q4416, Q4417, Q4418, Q4419, Q4420, Q4421, Q4422, Q4423, Q4424, Q4425, Q4426, Q4427, Q4428, Q4429, Q4435, Q4436, Q4437, Q4438, Q4439, and Q4440
  • For HCPCS Code Table 3, removed the following codes: A2012, C9363, Q4100, Q4108, Q4116, Q4122, Q4130, Q4182, Q4210, Q4231, and Q4244

To review all policies, please visit Superior’s Clinical, Payment & Pharmacy Policies webpage.

Prior to updates, Medical Clinical policies are reviewed and approved by the Utilization Management Committee.

For questions or additional information, contact Superior’s Prior Authorization department at 1-800-218-7508.