MedicaidPrior AuthHigh impact
Applied Behavior Analysis - MEDICAID - LOUISIANA (Revised)
Humana·LA · Wound Care, Podiatry, General Surgery +2 more·Medicaid
Effective date
Oct 7, 2026
We identified it
Oct 2, 2026
Summary
This is a NEW Humana Louisiana Medicaid policy (effective 10/07/2026) establishing coverage criteria for skin and tissue substitutes limited to partial and full-thickness diabetic lower extremity ulcers only. All other indications are not covered. Coverage requires prior authorization, comprehensive wound care documentation, specific clinical criteria (ulcer ≥1 cm, ≥4 weeks duration, no measurable healing despite therapy), HbA1c ≤9%, adequate circulation, and is capped at 10 treatments per 12 weeks with a hard stop after 5 applications without improvement.
Action Required
Before 10/07/2026: Billing team must implement prior authorization requirement in billing system for all skin and tissue substitute claims (Q4101, Q4121, Q4160, Q4186, Q4195, Q4196) for Louisiana Medicaid members. Update claim submission workflow to require attached medical documentation proving: (1) comprehensive wound care plan with offloading, smoking cessation counseling, edema control, diabetes/nutrition management, and comorbidity treatment; (2) ulcer characteristics (≥1 cm, ≥4 weeks duration, no measurable healing with conservative therapy); (3) HbA1c ≤9% within 90 days; (4) adequate circulation evidence (ABI ≥0.7, TBI ≥0.5, TcPO2 ≥30 mm Hg, or triphasic/biphasic Doppler); (5) exclusions ruled out (no active Charcot, autoimmune disease, malignancy, radiation/chemotherapy, prior treatment within 1 year). Add hard-stop logic: deny claims beyond 5 applications per ulcer and beyond 10 treatments per 12-week period. Update provider ordering templates to include checklist confirming all criteria met. Train front desk and billing staff on new limitations. Communicate to wound care and podiatry providers that skin substitutes are covered ONLY for diabetic lower extremity ulcers—all other indications (venous ulcers, burns, breast reconstruction, plantar fasciitis, etc.) are NOT covered effective this date. Failure to obtain prior authorization will result in claim denials.