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New Clinical Policies Effective in June and August 2018

Date: 05/01/18

Superior HealthPlan has recently introduced new clinical policies for providers that serve the following members:

  • Ambetter from Superior HealthPlan
  • CHIP
  • Medicaid (STAR, STAR+PLUS, STAR Kids and STAR Health)
  • STAR+PLUS Medicare-Medicaid Plan (MMP)
  • Allwell from Superior HealthPlan (Medicare Advantage - HMO and HMO SNP)

The following policies are effective on June 1, 2018 for MMP and Medicare Advantage Programs, and August 1, 2018 for Ambetter, Medicaid and CHIP Programs (as applicable). A brief summary of and hyperlink to the new clinical policies are included below. The diagnosis and procedural code combinations associated with each policy for claim filing and reimbursement purposes are detailed within. 

Please review each of Superior’s clinical policies, as they define Superior’s payment for certain procedural codes, based on medical necessity:

Thyroid Hormones and Insulin Testing in Pediatrics – It is the policy of Superior HealthPlan that thyroid hormone testing and insulin testing in heatlhy, including obese but otherwise healthy, children (age ≥ 1 and ≤ 18) are not medically necessary because these tests have not been demonstrated to have a clear clinical benefit.

25-hydroxyvitamin D Testing in Children and Adolescents – It is the policy of Superior HealthPlan that 25-hydroxyvitamin D testing in healthy, including obese but otherwise healthy, children (age ≥ 1 and ≤ 18) are not medically necessary because these tests have not been demonstrated to have a clear clinical benefit.

Measurement of Serum 1 ,25-digydrozyvitamin D – It is the policy of Superior HealthPlan that measurement of serum 1,25(OH)2D for routine screening of average risk, asymptomatic individuals is not medically necessary.

EEG in the Evaluation of Headache– It is the policy of Superior HealthPlan that an EEG in the routine evaluation of headache is not medically necessary.  EEG has not been convincingly shown to identify headache subtypes, nor has it been shown to be an effective screening tool for structural causes of headache.

Cardiac Biomarker Testing for Acute Myocardial Infarction – It is the policy of Superior HealthPlan that troponin I or T testing is medically necessary for suspected acute myocardial infarctions (AMI), but that creatine kinase myocardial isoenzyme (CK-MB) and myoglobin testing are not medically necessary for suspected AMI because these tests have not been demonstrated to have a clear clinical benefit.

Helicobacter Pylori Serology Testing – It is the policy of Superior HealthPlan that H. pylori serology testing is not medically necessary for diagnosing infection or evaluating treatment effectiveness.

For any questions on these policies, please reach out to your local Account Manager, or contact Provider Services at 1-877-391-5921.