Clarification: Lumbar Sacral Orthotics Criteria

Date: 08/26/24

Due to anticipated upcoming updates to CP.MP.107 Durable Medical Equipment (DME) and Orthotics and Prosthetics Guidelines Superior HealthPlan will continue to utilize Change Healthcare’s InterQual as the medical necessity review criteria for Lumbar Sacral Orthotics for applicable products listed below.

Superior ensures medical necessity review criteria is current and appropriate for members and the scope of services provided.

DME Service/Procedure	Applicable Products	Criteria
Lumbar Sacral Orthotics	Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter from Superior HealthPlan	Change Healthcare’s InterQual criteria, proprietary, but available upon request.

To review prior authorization requirements, please visit Superior’s Prior Authorization webpage.

For questions or additional information, contact Superior’s Prior Authorization department at 1-800-218-7508.