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Effective July 31, 2025: Clinical Policies

Date: 07/25/25

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.

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

Bone-Anchored Hearing Aid

(TX.CP.MP.522)

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

Policy updates include:

  • Table updated to include L8694
  • Added clarifying language to Section I. B. “where the condition prevents restoration of hearing using a conventional air-conductive hearing aid”
  • Section I. C. replaced “<70 dB HL” with “is consistent with the FDA indications for the requested device”

Caudal or Interlaminar Epidural Steroid Injections

(CP.MP.164)

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

Policy updates include:

  • Removed “and the member/enrollee is not currently being treated with full anticoagulation therapy
  • If on warfarin, international normalized ratio (INR) should be ≤ 1.4 prior to the procedure” from criteria

 

Facet Joint Interventions

(CP.MP.171)

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

Policy updates include:

  • Updated Criteria I.A.1.b.i. regarding physical therapy
  • Note added under Criteria I.A.1.b.i. regarding physical therapy or prescribed home exercise program in the presence of a facet joint synovial cyst
  • Removed Criteria I.A.1.b.ii. regarding activity modification
  • Updated Criteria I.A.1.c. to include notation about facet joint synovial cystU

Fetal Surgery in Utero for Prenatally Diagnosed Malformations

(CP.MP.129)

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

Policy updates include:

  • Removed specific degree requirement for severe kyphosis in Criteria I.G.5.a
  • Removed previous Criteria I.G.5.d. regarding maternal BMI contraindication
  • Added clarifying language to Criteria III

NICU Discharge Guidelines

(CP.MP.81)

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

Policy updates include:

  • Updated normal ambient temperature range in Criteria II.A

Pediatric Liver Transplant

(CP.MP.120)

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

Policy updates include:

  • Removed “at time of diagnosis” from criteria I.B.5.d. and I.B.5.k
  • Under I.B.7.c. reformatted criteria with no impact to criteria
  • Under I.C.4. updated glomerular filtration rate from <40 to < 30

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.