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Effective April 15, 2024: Cranial Molding Orthosis

Date: 03/15/24

Superior HealthPlan will utilize Change Healthcare’s InterQual as the medical necessity review criteria of Cranial Molding Orthosis (S1040) for Medicaid and Children’s Health Insurance Program (CHIP) members effective April 15, 2024. Superior ensures medical necessity review criteria is current and appropriate for members and the scope of services provided.

Procedure Code

Applicable Products


S1040 - Cranial molding orthosis

Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP

Change Healthcare’s InterQual criteria, proprietary, but available upon request 

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.