Effective March 27, 2023: Clinical Policies

Date: 03/22/23

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 March 27, 2023, 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
Gender-Affirming Procedures (CP.MP.95)	Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter	Policy updates include: Criteria updated to incorporate WPATH Standards of Care version 8 (SOC-8) Noted that intersex individuals are not subject to this criteria I Background updated to reflect updates in WPATH SOC-8
Stereotactic Body Radiation Therapy (CP.MP.22)	Ambetter	Policy updates include: Added I.F. “Recurrent malignant disease requiring palliation and/or as palliative treatment for liver-related symptoms” Added to criteria I.I “Inoperable spinal tumors” Added I.K. “Extracranial oligometastatic disease: 1. One to three metastatic lesions involving the lungs, liver or bone; 2. Primary tumor is breast, colorectal, melanoma, non-small cell lung, prostate, renal cell, or sarcoma; 3. Primary tumor is controlled; 4. No prior history of metastatic disease”

POLICY

APPLICABLE PRODUCTS

NEW POLICY OVERVIEW OR UPDATED POLICY REVISIONS

Gender-Affirming Procedures

(CP.MP.95)

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

Policy updates include:

Criteria updated to incorporate WPATH Standards of Care version 8 (SOC-8)
Noted that intersex individuals are not subject to this criteria I
Background updated to reflect updates in WPATH SOC-8

Stereotactic Body Radiation Therapy

(CP.MP.22)

Ambetter

Policy updates include:

Added I.F. “Recurrent malignant disease requiring palliation and/or as palliative treatment for liver-related symptoms”
Added to criteria I.I “Inoperable spinal tumors”
Added I.K. “Extracranial oligometastatic disease: 1. One to three metastatic lesions involving the lungs, liver or bone; 2. Primary tumor is breast, colorectal, melanoma, non-small cell lung, prostate, renal cell, or sarcoma; 3. Primary tumor is controlled; 4. No prior history of metastatic disease”

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, please contact Superior HealthPlan Prior Authorization department at 1-800-218-7508.