Effective January 22, 2024: Clinical Policies
Date:
01/17/24
Superior HealthPlan has updated certain 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 January 22, 2024, 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
|
|---|
Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea (CP.MP.180)
| Ambetter
| Policy updates include:
- Updated criteria B. from "Age > 22 years" to "BMI ≤ 40 kg/m2"
- Changed C. from "BMI < 35 kg/m2" to "One of the following:"
- Added C.1 to C.3, indicating the updated age ranges and associated criteria
- Contraindications were updated to I.D.a to I.D.g
- Criteria points I.E to I.I were removed
|
Mechanical Stretching Devices for Joint Stiffness and Contracture (CP.MP.144)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter
| Policy updates include:
- Added ankle to Criteria I
- Rearranged Criteria I.A. for clarification and added Criteria I.A.1.c. stating that low-load prolonged-duration stretch (LLPS) device/dynamic stretch device is provided with or without adjunctive physical therapy
- Specified in I.B. that criteria is for a rental
- Removed code E1815 from HCPCS codes that do not support coverage and added to HCPCS codes that do support coverage
|
Proton and Neutron Beam Therapies (CP.MP.70)
| Ambetter
| Policy updates include:
- Updated criteria I.G. to, unresectable benign or malignant central nervous system tumors to include but not limited to primary and variant forms of astrocytoma, glioblastoma, medulloblastoma, acoustic neuroma, craniopharyngioma, benign and atypical meningiomas, pineal gland tumors, and arteriovenous malformations
- Added criteria I.H., Pituitary neoplasms
- Restructured and added section A. and B. to criteria II
|
Urinary Incontinence Devices and Treatments (CP.MP.142)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter
| Policy updates include:
- Added note under Description to refer to CP.MP.133 Posterior Tibial Nerve Stimulation for Voiding Dysfunction for posterior tibial nerve stimulation treatment for urinary incontinence
- Updated criteria I.B. from, urinary retention have been present for at least 12 months, to, urinary retention have been present for at least 6 months
|
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 HealthPlan Prior Authorization department at 1-800-218-7508.
