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Effective May 31, 2023: Clinical Policies

Date: 03/22/23

Superior HealthPlan has added a clinical policy 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 31, 2023.

POLICY

APPLICABLE PRODUCTS

NEW POLICY OVERVIEW

Allogeneic Hematopoietic Cell Transplants for Sickle Cell Anemia and β-Thalassemia

(CP.MP.108)

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

New Policy includes:

  • Added contraindication criteria I.C.1. through 4

Donor Lymphocyte Infusion

(CP.MP.101)

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

New Policy includes:

  • Added contraindication criteria I.C.1. through 4

Pancreas Transplantation

(CP.MP.102)

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

New Policy includes:

  • Removed criterion I.A. stating that medical treatment does not exist or has failed
  • Removed C-peptide values and BMI requirements from Criteria I.B.1 and I.B.2
  • Noted in I.B.1. that member/enrollees with requirements for insulin over one unit/kg should be closely evaluated as they may be less likely to benefit from pancreas transplant compared to those with lower insulin doses
  • Added indication in I.B.2 for exocrine pancreatic insufficiency
  • Added indication I.B.3. for requirement for the procurement or transplantation of a pancreas as part of a multiple organ transplant for technical reasons
  • Changed “chronic” to “active” in infection contraindication in I.C.7
  • Removed acute renal failure contraindication
  • Criteria I.C.12. updated to exclude marijuana use when prescribed by a licensed practitioner and include required commitment to reducing substance use behaviors if urgent transplant timelines are present
  • Added chronic, non-healing wounds as contraindication in Criteria I.C.13
  • Added contraindication of significant comorbidities in Criteria I.C.14
  • Clarified in I.C.1.b that problems with insulin could be clinical or clinical and emotional
  • Added in I.C.2.c. that the GFR does not have to be the most recent value
  • Added Criteria I.D.1.c. requirement for being medically managed by an endocrinologist for at least 12 months for pancreas transplant alone
  • Added requirements for SPK and PAK that PTA criteria also needs to be met for those procedures

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.