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Effective May 18, 2022: Clinical Policies

Date: 05/17/22

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 May 18, 2022, at 12:00 AM.

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

Sclerotherapy and Chemical Endovenous Ablation for Varicose Veins

(CP.MP.146)

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

Policy updates include:

  • Added I.C, that if cyanoacrylate adhesive (VenaSeal) is requested, it is for the small saphenous vein only
  • Removed section III stating that cyanoacrylate adhesive is not medically necessary
  • Removed table of codes that do not support medical necessity and added codes 36482 and 36483 to table of codes that support medical necessity

Skin Substitutes for Chronic Wounds

(CP.MP.185)

Ambetter

Policy updates include:

  • Added “type 2 diabetes” to I.A
  • Added to I.F.2. “unless Integra® is used per FDA guidelines”
  • Removed I.J.3. “Concurrent treatment with hyperbaric oxygen therapy”
  • Added the following HCPCS codes: A2001-A2010, Q4199, Q4201, Q4232 and Q4254
  • Removed Q4119 and Q4174
  • Added reference CMS A56696

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.