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Effective May 20, 2025: Clinical Policies

Date: 05/16/25

Ambetter from Superior HealthPlan and Superior HealthPlan have added and 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 20, 2025, 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

Air Ambulance

(CP.MP.175)

Ambetter

Policy updates include:

  • Description and Criteria I.B.1. updated to include water ambulance
  • Criteria I.B.2. updated for clarity

Home Ventilators

(CP.MP.184)

CHIP and Ambetter

New Policy Overview (CHIP):

  • Description
  • Policy and Criteria
  • Background
  • Coding Implications
  • Most recent update: CPT codes E0467 and E0468 added

Policy updates include (Ambetter):

  • CPT codes E0467 and E0468 added

 

Liposuction for Lipedema

(CP.MP.244)

Ambetter

Policy updates include:

  • Removed requirement for mandatory secondary review in policy statement I
  • Updated conservative treatment requirement in I.F. from six months to three months

Physical, Occupational, and Speech Therapy Services

(TX.CP.MP.549)

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

Policy updates include:

  • Changed Section III.D. duration of 3 months to “duration up to 24 weeks, not to exceed 180 days”

Sclerotherapy and Chemical Endovenous Ablation for Varicose Veins and Other Symptomatic Venous Disorders

(CP.MP.146)

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

Policy updates include:

  • Removed “only” from criteria in I.D.1
  • Removed requirement of a documented lidocaine allergy from criteria I.D.2

Transplant Service Documentation Requirements

(CP.MP.247)

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

Policy updates include:

  • Added requirements for post-transplant follow up visits and note in same section regarding other requests

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.