Update to Unit Limitations for Certain Medical Supplies

Date: 10/30/24

Effective July 1, 2024, Superior HealthPlan increased the internal limitation of allowed units for certain Medical Supplies for Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP and STAR+PLUS Medicare-Medicaid Plan (MMP). The supplies listed in the table below will not require prior authorization unless requested beyond the stated units in the New Internal Limitation Allowed per Month column.

Providers should only be ordering a quantity of supplies commensurate with the member’s documented needs in the medical record. Providers must maintain and retain all necessary medical documentation per Texas Administrative Code §371.1667.

Below are the medical supplies with Current Procedural Terminology (CPT) codes included in this change.

CPT Code	Description	New Internal Limitation Allowed per Month
A4232	SYR W/NEEDLE-EXT INSULIN PUMP, STER, 3CC	15
A4310	INSERT TRAY WO DRAIN BAG/CATHETER	8
A4311	INSERT TRAY WO DRAIN BAG W/INDWELL CATH LATEX	8
A4312	INSERT TRAY WO DRAIN BAG W/INDWELL CATH SILICON	8
A4313	INSERT TRAY WO DRAIN BAG W/3 WAY INDWELL CATH	8
A4314	INSERT TRAY W/DRAIN BAG & INDWELL CATH LATEX	8
A4315	INSERT TRAY W/DRAIN BAG & INDWELL CATH SILICONE	8
A4316	INSERT TRAY W/DRAIN BAG & I3 WAY INDWELL CATH	8
A4320	IRRIGATION TRAY W/BULB/PISTON SYRINGE	30
A4322	IRRIGATION SYRINGE BULB/PISTON EACH	60
A4332	LUBE IND STR PKT-URIN CATH INS EA	90
A4333	URIN CATH ANC DEV ADHES SKIN ATT EA	4
A4334	URIN CATH ANCHRG DEV LEG STRAP EA	4
A4335	INCONTINENCE SUPPLY MISC	4
A4338	INDW CATH FOLEY 2 WAY ATEX W/COATING EACH	4
A4340	INDWELL CATH SPECIALTY TYPE EACH	4
A4344	INDW CATH FOLEY 2 WAY SILICONE EACH	4
A4346	INDW CATH FOLEY 3 WAY CONT IRRIGATION	4
A4351	INTERMITTENT URINARY CATH STRAIGHT TIP EACH	240
A4352	INTERMITTENT URINARY CATH COUDE TIP EACH	240
A4353	INTERMITTENT URINARY CATHETER W/INSERTION SUPP	240
A4354	INSERTION TRAY W/DRAIN BAG W/O CATH	4
A4355	IRRIG TUB SET CONT IRRIG VIA FOLEY EACH	4
A4356	EXT URETHRAL CLAMP/COMPRESS DEVICE EACH	4
A4357	BDSD DRBG DAY/NIGHT W/WO TUB/ANTIREFLUX EACH	4
A4358	URINARY LEG BAG VINYL W/WO TUB EACH	4
A4402	LUBRICANT PER OUNCE	8
A4450	TAPE NON-WATERPROOF-18 SQUARE IN	150
A4452	TAPE WATERPROOF PER 18 SQUARE IN	150
A4455	ADHESIVE REMOVER/SOLVENT (TAPE-CEMENT) PER OUNCE	5
A4456	ADHESIVE REMOVER, WIPES	100
A4605	TRACHEAL SUCTION CATHETER, CLOSED SYSTEM, EACH	31
A4606	O2 PROBE W/OXIMETER DEVICE REPLCMT	8
A4606	O2 PROBE W/OXIMETER DEVICE REPLCMT	4
A4623	TRACHESTOMY, INNER CANNULA	2
A4629	TRACH CARE KIT FOR ESTABLISHED TRACHEOSTOMY	31
A5120	SKIN BARRIER WIPES OR SWABS EACH	60
A5200	PERCUTANEOUS CATHETER/TUBE ANCHORING DEVICE, ADHESIVE SKIN ATTACHMENT	4
A6196	ALGINATE DRESSING <=16 SQ IN	40
A6209	FOAM DRSG <=16 SQ IN W/O BDR	40
A6234	HYDROCOLLD DRG <=16 W/O BDR	40
A6257	TUBULAR DRESSING W OR W/O ELASTIC ANY WIDTH /LINEAR YARD	40
A7036	CHINSTRAP USE W/POS ARWAY PRSS DEVC	2
A7520 EQUAL	TRACHEOSTOMY/LARYNGECTOMY TUBE/N-CFFD/(PVC)/SILICONE OR	2
A7521 EQUAL	TRACHEOSTOMY/LARYNGECTOMY TUBE/CFFD/(PVC)/SILICONE OR	2
A7526	TRACHEOSTOMY TUBE COLLAR/HOLDER	31

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.