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Effective April 15, 2022: New Clinical Payment Policy - Gastrointestinal Pathogen Nucleic Acid Detection Panel Testing

Date: 01/19/22

Superior HealthPlan presents a new payment policy to communicate the medical necessity criteria for Gastrointestinal Pathogen Nucleic Acid Detection Panel Testing. As a result, the following policy has been added, and is posted on Superior’s Clinical, Payment and Pharmacy Polices webpage for review, prior to its implementation:

POLICY

EFFECTIVE DATE

APPLICABLE PRODUCTS

NEW POLICY OVERVIEW OR UPDATED POLICY REVISIONS

Gastrointestinal Pathogen Nucleic Acid Detection Panel Testing (CP.MP.209)

04/15/2022

Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, Health Insurance Marketplace (Ambetter from Superior HealthPlan, Medicare (Wellcare By Allwell [HMO and HMO SNP])

  • Gastrointestinal pathogen panel testing of up to five targets is considered medically necessary for either of the following:
    A. Diarrhea for more than seven days with fever and suspected bacteremia; B. Suspected enteric fever or who has consumed foods prepared by people with recent endemic exposure.
  • Gastrointestinal pathogen panel testing of up to 11 targets is considered medically necessary for either of the following: A. Diarrhea for more than seven days with fever and suspected bacteremia, and the individual is at risk for Clostridium difficile (C. difficile) colitis; B. Persistent diarrhea in immunocompromised individuals.
  • Gastrointestinal pathogen panel testing of greater than 11 targets is considered medically necessary for persons who are critically ill or immunocompromised in a healthcare setting, such as emergency department or inpatient hospital, including those in observation status.

To review all payment policies, please visit Superior’s Clinical, Payment and Pharmacy Polices webpage.

For questions or additional information, please contact Superior Provider Services at:

  • 1-877-391-5921 (Medicaid [STAR, STAR Health, STAR Kids, STAR+PLUS], CHIP, Wellcare By Allwell [HMO, HMO SNP])
  • 1-877-687-1196 (Ambetter from Superior HealthPlan)