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Effective November 30, 2026: Clinical Policies
Effective date
Nov 30, 2026
Identified
Sep 18, 2026
Summary
Effective November 30, 2026 at 12:00 AM, Ambetter Health and Superior HealthPlan updated several clinical policies for Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP and Ambetter Health products. A new policy sets medical necessity criteria for skin and soft tissue substitutes for diabetic foot ulcers, venous leg ulcers and burns, covering up to four initial applications and continued treatment up to ten applications per wound per 12-week episode. Selective nerve root block criteria now apply to diagnostic purposes only, and all therapeutic indications were removed.
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What to do
Action · 10 steps
01Effective November 30, 2026 at 12:00 AM: Providers and the billing team must meet the new skin substitute criteria for Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS) and CHIP members.
02Requests must be for one of the preferred products listed in the policy, and only one skin substitute may be in place per wound episode.
03Document wound measurements at baseline and follow-up, the procedure with the product used (package label or NDC in the chart) and product size, and keep all documentation in the member's medical record.
04If part of a product is discarded, document the amount administered and wasted, the date, time, amount and reason for the wastage.
05Initial treatment covers up to four applications, and continued treatment is covered up to ten applications per wound per 12-week episode of care.
06Skin substitute products used in a facility setting are part of the application services and are not separately reimbursed.
07The Cosmetic and Reconstructive Procedures policy adds code 54163 (repair incomplete circumcision).
08Selective nerve root block criteria are for diagnostic purposes only, and therapeutic indications were removed.
09Ankle-foot orthotics (L1933, L1952) and lower extremity prosthetics (L8030, L8035) were removed from the durable medical equipment policy, and Walkasins (L8720, L8721) are not medically necessary.
10Providers should reference the most up-to-date coding guidance before submitting claims.
Codes mentioned
54163L1933L1952L8030L8035L8720L87211527115272152731527415275152761527715278G0681G0682G0683G0684Q4101Q4102Q4104Q4105Q4108Q4121Q4132Q4133Q4158Q4186
Original notice
Effective November 30, 2026: Clinical Policies
ambetterhealth.com · Always check the source before changing claims.
Related changes
See all Ambetter changes →Related policy hubs
Ambetter policiesTX policy changesWound CarePlastic SurgeryPain ManagementOrthopedicsPodiatryHematologyOncologyCode 54163Code L1933Code L1952Code L8030Code L8035Code L8720Code L8721Code 15271Code 15272Code 15273Code 15274Code 15275Code 15276Code 15277Code 15278Code G0681Code G0682Code G0683Code G0684Code Q4101Code Q4102Code Q4104Code Q4105Code Q4108Code Q4121Code Q4132Code Q4133Code Q4158Code Q4186