Effective June 7, 2021: Clinical Policies
Date:
05/28/21
Superior HealthPlan has either created new policy, revised or retired existing clinical 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 have been created, revised or retired. These policies are effective on June 7, 2021 at 12:00AM.
Please note: The newly created or revised policy referenced in this notice correlates with the version currently posted on Superior’s Policies webpage. For existing policy revisions, please reference the revision log in each policy to identify the proposed revision for the applicable policy.
POLICY
| APPLICABLE PRODUCTS
| NEW POLICY OVERVIEW, POLICY REVISIONS OR POLICY RETIRED:
|
|---|
Gender Affirming Procedures
CP.MP.95
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS) CHIP and Ambetter
| Policy revisions include:
- Added characteristics of a mental health provider to II.F and II.G
- Revised criteria in II.G to allow second referral letter from a qualified mental health provider, rather than limiting to psychologist or psychiatrist
- References reviewed and updated
- Description of CPT 11970, 19325 revised in 2021. CPT 19324, 58293 deleted in 2021
- Replaced “member” with “member/enrollee”
|
Hospice
CP.MP.54
| Ambetter
| Policy revisions include:
- Reviewed and updated references
- Updated “creatinine clearance < 10 (or < 15 with diabetes), or creatinine clearance < 15 with CHF (or < 20 with diabetes and CHF)” to “creatinine clearance <15 ml/min” per LCD L34538 update
- Moved hospice description from background section to policy description section
- Replaced all instances of “member” with “member/enrollee"
- Codes reviewed
|
Panniculectomy
CP.MP.109
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS) CHIP and Ambetter
| Policy revisions include:
- Annual review
- Replaced all instances of member with member/enrollee
- Expanded criteria for complications related to pannus to include:
- non-healing ulceration under panniculus
- chronic maceration or necrosis of overhanging skin folds
- recurrent or persistent skin infection under panniculus
- intertriginous dermatitis or cellulitis or panniculitis
- Added the following ICD 10 codes: L03.319, L03.818, and L98.499
- Separated “D” into separate criteria points, D and E, adding that bariatric surgery weight loss must be stable for 6 months
|
Total Parenteral Nutrition and Intradialytic Parenteral Nutrition
CP.MP.163
| CHIP and Ambetter
| Policy revisions include:
- Added indications for radiation enteritis, liver failure in children, liver failure in adults, and acute necrotizing pancreatitis in adults, in I.A.2.j – I.A.2.m., along with relevant ICD-10 codes (i.e., K52.0, K72.00-K72.91, K85.01, K85.02, K85.11, K85.12, K85.31, K85.32, K85.81, K85.82, K85.91, K85.92 and Z76.82
- In I.B.2, changed “end-stage renal disease” to “stage 5 chronic kidney disease”
- References reviewed and updated and coding reviewed
- Replaced member with member/enrollee in all instances
- Replaced “experimental/investigational” with “not proven safe and effective” in section II
|
To review all Clinical 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.
