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Effective July 31, 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 July 31, 2024, at 12:00AM.




Deep Transcranial Magnetic Stimulation for the Treatment of Obsessive Compulsive Disorder



Policy updates include:

  • Separated former criteria point I.A into two sub points (A and B)
  • Criteria point I. D. reworded for clarity “Direct supervision of treatment is provided by a licensed psychiatrist except where state scope of practice acts allows for other provider types to supervise”
  • Removed I.H.3. “Vagus nerve stimulator leads in the carotid sheath” as this is captured in I.H.2.h
  • In criteria point I.H.4. replaced “substance abuse at time of treatment” with “less than three months of substantiated remission from a substance use disorder”
  • Removed “Neurological disease or head injury” and “pregnancy” from the contraindication list
  • Added new CPT/HCPCS codes: “97014: Application of a modality to 1 or more areas; electrical stimulation (unattended); 97032: Application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes

Transcranial Magnetic Stimulation for Treatment Resistant Major Depression



Policy updates include:

  • Criteria point I.D. added that the pre-TMS score should be documented in order to measure progress more effectively “Planned use of a depression severity standardized rating scale by the TMS provider to monitor response during treatment, “with pre-TMS score documented”
  • Removed prior criterion I.G. and reworded criteria regarding trial and failure of psychopharmacologic therapy and psychotherapy in new I.G and I.H. to include the requirement for a standardized scale to indicate moderate to severe depression throughout treatment
  • In I.G., clarified that the member/enrollee must present with the “failure or intolerance to two trials of psychopharmacologic agents from at least two different agent classes”
  • In I.G.2, required that both criteria a and b be met for intolerance
  • In G.2.b, specified that “at least 4 antidepressants representing at least 2 different drug classes” must have been attempted
  • In I.H., added a note that the therapy should overlap with medication trials
  • In I.J., added contraindication “concomitant esketamine intranasal, ketamine infusion, or other infusion therapies”
  • Removed HCPCS coding table including G0295


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.