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Effective June 28, 2024: Clinical Policies

Date: 05/22/24

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 June 28, 2024, at 12:00AM.




Bariatric Surgery (CP.MP.37)

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

Policy updates include:

  • Removed high risk for type 2 DM in Criteria I.A.1.a.ii.c)i)
  • Changed Criteria I.A.1.a.ii.c)ii) from poorly controlled hypertension to hypertension
  • Removed severe urinary incontinence from Criteria I.A.1.a.ii.c)xii)
  • Updated verbiage in Criteria I.A.1.a.ii.c)xiii) to bone and joint diseases
  • Removed idiopathic intracranial hypertension from Criteria I.A.1.a.ii.c)xiv) since duplicative since pseudotumor cerebri is in criteria
  • Added chronic kidney disease in Criteria I.A.1.a.ii.c)xiii)
  • Added infertility in Criteria I.A.1.a.ii.c)xiv)
  • Added polycystic ovarian syndrome in Criteria I.A.1.a.ii.c)xv)
  • Clarified verbiage in Criteria I.A.1.b
  • Updated Criteria I.A.1.b.ii.d) to state nonalcoholic fatty liver disease or nonalcoholic steatohepatitis
  • Criteria Clarified verbiage in Criteria I.B.1. and in Criteria I.B.1.a
  • Updated Criteria I.B.1.b.iv. from glomerular filtration rate (GFR) < 30 mL/min-1 to GFR < 60 mL/min-1
  • Added Criteria I.B.1.b.vii. to include unstable angina
  • Added Criteria I.B.1.b.viii. to include recent myocardial infarction (within the past 60 days)
  • Updated Criteria I.B.4. to include thiamine, calcium, and fat-soluble vitamins
  • In I.B.5., removed requirement for monthly nutritional counseling
  • Updated verbiage to Criteria I.B.9. to state gastrointestinal (GI) screening and evaluation for clinically significant GI symptoms with documentation of needed treatment prior to bariatric surgery
  • Removed Criteria I.B.10. for Helicobacter pylori screening
  • Minor rewording in Criteria I.B.11
  • Updated Criteria III.B. to include other names of procedure for clarification
  • Minor rewording in Criteria III.K
  • Removed one-anastomosis gastric bypass in Criteria III.L. since duplicative

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’s Prior Authorization department at 1-800-218-7508.