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Effective July 31, 2025: Clinical Policies

Date: 05/15/25

Ambetter from Superior HealthPlan and 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, 2025, at 12:00AM.

Policy

Applicable Products

New Policy Overview or Updated Policy Revisions

Intestinal and Multivisceral Transplant

(CP.MP.58)

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

Policy updates include:

  • Added clarifying language in Policy/Criteria section and in Criteria II.A.1
  • Updated Criteria II.A.1.a. to include TPN induced liver injury for clarity and changed “peristomal” to “stomal”
  • Added hospitalization requirement for clarity in Criteria II.A.1.c
  • Separated Criteria II.A.1.c. into two criteria points
  • Clarifying language added to Criteria II.A.1.d
  • Updated “post-mesenteric” to “portomesenteric” in Criteria II.A.2.5
  • Updated GFR from < 30 mL/min/1.73m2 to < 40 mL/min/1.73m2 in Criteria II.B.3
  • Removed information about heart transplant waiting list from Criteria II.B.4.b
  • Removed Criteria II.B.5. for other GI diseases
  • Removed Criteria II.B.6. for acute liver failure or cirrhosis with portal hypertension or synthetic dysfunction unless being considered for multi-organ transplant
  • Removed Criteria II.B.12. contraindication regarding absence of an adequate support system

Skin and Soft Tissue Substitutes for Chronic Wounds

(CP.MP.185)

Ambetter

Policy updates include:

  • Removed note under description to refer to MC.CP.MP.185 for Medicare plans
  • Updated and replaced previous criteria I.A. through I. with new criteria I.A. through G
  • Updated and replaced previous criteria II.A. through C. with new criteria I.A. through G
  • Description and Background reviewed and updated
  • Coding updated to reflect addition of preferred product list in criteria I.E

 

Therapeutic Utilization of Inhaled Nitric Oxide

(CP.MP.87)

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

Policy updates include:

  • A Merged changes and revision log entries from 11/24 and 7/24 policy versions. Under I.A.6. changed oxygen index (OI) >20 to 25. Moved I.A.7. to III.A.1. Removed criteria under III.A.1. Continues to require iNO as evidenced by a continued O2 requirement of 80 to 100% in the absence of iNO

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.