Effective March 25, 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 March 25, 2024, at 12:00AM.

Changes in these policies reflect preauthorization requirement amendments that are less burdensome to insureds, physicians, or health care providers.

POLICY	APPLICABLE PRODUCTS	NEW POLICY OVERVIEW OR UPDATED POLICY REVISIONS
Assisted Reproductive Technology (CP.MP.55)	Ambetter	Policy updates include: Added criteria I.B.5.h. to include “and oocytes that have undergone in vitro maturation Added criteria I.B.6.h. Hypergonadotropic hypogonadism Added criteria I.B.8.b. Partner with male reproductive system has ejaculatory dysfunction Expanded criteria I.B.8.c.to include severe oligozoospermia, or other significant sperm or seminal fluid abnormalities
Heart-Lung Transplant (CP.MP.132)	Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter	Policy updates include: Added indication to criteria I.A.1.j Expanded criteria I.C.1. to I.C.1.a. through c Removed contraindication I.C.17., active peptic ulcer disease
Lantidra (donislecel): Allogeneic pancreatic islet cellular therapy (CP.MP.250)	Ambetter	Policy updates include: Added note to description regarding Medicare policy version Removed maximum age requirement from Criteria I.A
Nonmyeloablative Allogeneic Stem Cell Transplants (CP.MP.141)	Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter	Policy updates include: · Removed Hodgkin’s lymphoma from Criteria I.A.9. per updated National Comprehensive Cancer Network (NCCN) recommendations Added Criteria I.A.13.e. to include polycythemia vera Updated Criteria I.B.4.b. from diffusing capacity of the lung for carbon monoxide (DLCO) ≤ 50% of predicted value to DLCO ≤ 60% of predicted value Removed absolute contraindications in Criteria I.C
Pancreas Transplantation (CP.MP.102)	Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter	Policy updates include: Expanded criteria I.B. to I.B.a. through c
Stereotactic Body Radiation Therapy (CP.MP.22)	Ambetter	Policy updates include: Updated cancer staging in Criteria I.A. to align with National Comprehensive Cancer Network (NCCN) guidelines Criteria II.C. updated to include details regarding positive clinical indications regarding Stable systemic disease Karnofsky Performance Score Survival expectations Eastern Cooperative Oncology Group (ECOG) Performance Status to align with ASTRO 2022 Model Policy for SRS Added “one of the following” to I.J. Criteria II.J. added to include trigeminal neuralgia and select cases of medically refractory epilepsy movement disorders such as Parkinson’s disease and essential tremor and hypothalamic hamartomas to align with 2022 ASTRO Model Policy for SRS
Tandem Transplant (CP.MP.162)	Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter	Policy updates include: Added a. through c. to I.B.10.; a. CD4 cell count > 200 cells/mm3 b. Absence of active AIDS-defining opportunistic infection c. Member/enrollee is currently on effective ART (antiretroviral therapy)

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.