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Effective May 27, 2024: Clinical Policies

Date: 05/22/24

Superior HealthPlan has updated certain 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 are effective on May 27, 2024, at 12:00AM.

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

Lung Transplantation

(CP.MP.57)

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

Policy updates include:

  • Updated I.C.2. from GFR < 40 mL/min/1.73m2 to GFR < 30 mL/min/1.73m2
  • Expanded I.C.9. with qualifying criteria for members who are HIV positive
  • Updated I.D.2.a.1. from FEV1<25% to FEV1<30%

Pediatric Kidney Transplant

(CP.MP.246)

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

Policy updates include:

  • Updated contraindication I.B.2, adding a. through c

Skin and Soft Tissue Substitutes for Chronic Wounds

(CP.MP.185)

Ambetter

Policy updates include:

  • In note and policy statements I and II, specified that this policy applies to non-Medicare plans
  • Removed language related to venous stasis ulcers
  • Removed criteria 1.A Age ≥ 18 years, or diabetic (Type 1 or Type 2)
  • Removed “including silver dressings in C.1
  • Replaced C2 “wound has increased in size or depth or has not changed… with “Wound area has reduced <50% in four weeks”
  • Updated description for HCPCS code A4225
  • Removed the following codes from HCPCS codes that do not support medical necessity criteria and added to table for HCPCS codes that support medical necessity criteria: A2002, Q4236, and Q4262
  • Added HCPCS code Q4278 to table for HCPCS codes that support medical necessity criteria
  • Added the following codes to table for HCPCS codes that do not support medical necessity criteria: Q4279 and Q4287 through Q4304

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’s Prior Authorization department at 1-800-218-7508.