Effective May 31, 2024: Clinical Policies
Date:
03/20/24
Superior HealthPlan has 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 May 31, 2024, at 12:00AM.
POLICY
| APPLICABLE PRODUCTS
| NEW POLICY OVERVIEW OR UPDATED POLICY REVISIONS
|
Gastric Electrical Stimulation
(CP.MP.40)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter
| Policy updates include:
- Added I.A. "Member/enrollee is ≥ 18 years of age"
- Updated I.B. to include "diabetic or" in describing type of gastroparesis
- Updates made to CPT code descriptions
|
Implantable Intrathecal or Epidural Pain Pump (CP.MP.173)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter
| Policy updates include:
- Restructured and reformatted criteria section
- In I.B. and II.B. added contraindications to include known allergies to materials in the implant;
- Active alcohol or drug abuse, including but not limited to:
- Opioid addiction and intravenous drug abuse
- Diagnosis of dementia or psychosis
- Active systemic infection
- Active infection at the site of implantation
|
Outpatient Oxygen Use (CP.MP.190)
| CHIP, and Ambetter
| Policy updates include:
- Updated all criteria instances of "blood gas study" to include "or pulse oximetry measurement" and all instances of “arterial oxygen saturation” to include “(or pulse oximetry)”
- Changed age requirements in I. and III. from ≥ 21 to ≥ 18 years of age
- Changed age requirements in II and IV from <21 to <18 years of age
- Added clarifying language to Criteria I.B.1.a. regarding breathing room air
- In I. B.1.b., I.B.1.c., and I.B.2.a., removed the requirement that the measurement is taken after 5 minutes of sleep vs. during sleep
- Criteria I.D.2. updated to reflect condition requirements for blood gas study not performed during an inpatient hospital stay
- Removed I.E. regarding alternative treatments
- Added clarifying language to Criteria II.A.2. for cystic fibrosis complicated by severe chronic hypoxemia
- Updated Criteria II.A.4. to state Bronchopulmonary dysplasia (BPD) complicated by chronic hypoxemia
- Added Criteria II.A.9. to include pulmonary hypertension without congenital heart disease complicated by chronic hypoxemia
- Added Criteria II.A.10. to include interstitial lung disease complicated by severe chronic hypoxemia
- Updated Criteria II.B.1. and Criteria II.B.2. to include requirements for SpO2 measurements for children younger than one year old and for children aged one year or older
- Clarifying language added to Criteria V.C. regarding the absence of systemic hypoxemia
- Added Criteria V.E. to include terminal illnesses that do not affect the ability to breathe
- Added Criteria VI.A.3. to include frequency of headache attacks
|
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 HealthPlan Prior Authorization department at 1-800-218-7508.
