MedicaidPrior AuthMedium impact
Skin and Tissue Substitutes - MEDICAID - LOUISIANA (Revised)
Humana·LA · Wound Care, General Surgery, Dermatology +2 more·Medicaid
Effective date
Oct 7, 2026
We identified it
Oct 6, 2026
Summary
Humana Louisiana Medicaid revised its Skin and Tissue Substitutes policy effective 2026-10-07, maintaining coverage for diabetic lower extremity ulcers only under strict clinical criteria (minimum 4-week duration, at least 1 cm², no measurable healing, HbA1c ≤9%, documented comprehensive treatment plan). Coverage is limited to maximum 10 treatments in 12 weeks, with discontinuation after 5 applications if no improvement. All other indications remain non-covered. Prior authorization is required for all applications.
Action Required
Effective 2026-10-07: Billing team must implement prior authorization requirement for all skin and tissue substitute claims (Q4101, Q4121, Q4160, Q4186, Q4195, Q4196) for Louisiana Medicaid Healthy Horizons members. Update billing system to flag claims requiring documentation of: (1) comprehensive treatment plan including offloading, smoking cessation counseling, edema control, diabetes/nutrition improvement, and comorbidity treatment; (2) ulcer persistence ≥4 weeks and ≥1 cm² with no measurable healing despite comprehensive therapy; (3) HbA1c ≤9% within 90 days; (4) adequate circulation (ABI ≥0.7, TBI ≥0.5, TcPO2 ≥30 mm Hg, or triphasic/biphasic Doppler waveform); (5) absence of active Charcot deformity, untreated autoimmune disease, malignancy, radiation/chemotherapy, or re-treatment within one year. Implement treatment limitation: maximum 10 applications per 12-week period with automatic denial after 5 applications if no measurable decrease in surface area or depth. Consequence: Claims submitted without prior authorization documentation or exceeding utilization limits will be denied.