Effective January 31, 2025: Clinical Policies

Date: 11/20/24

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 January 31, 2025, at 12:00AM.

POLICY	APPLICABLE PRODUCTS	NEW POLICY OVERVIEW OR UPDATED POLICY REVISIONS
Electric Tumor Treating Fields (Optune) (CP.MP.145)	Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter	Policy updates include: Changed I.A.1.a.ii. from ≥ 60 to Karnofsky Performance Status of ≥ 70 Added I.A.1.b.ii. "Member has good performance status, as defined by a Karnofsky Performance status rating of ≥ 70

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.