Effective June 30, 2026: Clinical Policies
Date:
05/20/26
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 30, 2026, at 12:00AM.
Policy
| Applicable Products
| New Policy Overview or Updated Policy Revisions
|
Enteral Nutrition and Supplies
(TX.CP.MP.550)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), and CHIP
| Policy updates include:
- Updated policy header to “necessary when a complete DME or Medical Supply Order in Section I is submitted and the individual criteria under Sections II, III, or IV are met”. Added Section I for DME order from TX.CP.MP.552 with no changes to criteria for ease of reviewer use
- Added Section III.D. “Donor Breast Milk” in its entirety for ease of reviewer use from TMPPM with donor milk form as link and required elements from the form in policy language for provider ease
- Section IV. H. 3 updated per FDA age requirements “Requested amounts are aligned with FDA approval of: Member is age one or older. For neonates and infants 6 months of age or younger, up to 2 cartridges can be used in a day (24-hour period). For infants greater than 6 months of age, pediatric and adult patients, up to 6 cartridges can be used in a day (24-hour period). Requests beyond the Texas Medicaid benefit limitation of 62 cartridges per month for B4105 require mandatory secondary review by a medical director advisor to determine medical necessity”
|
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.
