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
|
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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.