Effective March 31, 2025: Clinical Policies
Date:
01/17/25
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 March 31, 2025, at 12:00AM.
POLICY
| APPLICABLE PRODUCTS
| NEW POLICY OVERVIEW OR UPDATED POLICY REVISIONS
|
Hyperhidrosis Treatments (CP.MP.62)
| Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter
| Policy updates include:
- Updated criteria I.E.3. by removing (hyperhidrosis often improves pregnancy)
- Removed previous Criteria I.E.5. regarding cracked skin near the treatment area
- Added epilepsy to Criteria I.E.5
- Updated Criteria II.A. to include through Criteria I.E
- Updated Criteria III.A. to include through Criteria I.E
- Added diathermy to notation at end of coding section regarding insufficient evidence in the peer-reviewed literature
|
Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea
(CP.MP.180)
| Ambetter
| Policy updates include:
- Updated I.C.3.a. from apnea-hypopnea index (AHI) of >15 and < 100 to ≥ 15 and ≤ 100
- Added contraindication I.D.8. Member/enrollee has rhabdomyolysis
|
Proton and Neutron Beam Therapies
(CP.MP.70)
| Ambetter
| Policy updates include:
- Updated Criteria I.A. to include intraocular melanomas and removed language regarding fiducial markers
- Added clarifying language to Criteria I.B. regarding primary spine or spinal cord tumors or metastatic tumors of the spine or spinal cord where organ at risk tolerance may be exceeded with photon treatments
- Updated Criteria I.D. by removing “Primary” and including intra-hepatic biliary cancers
- Updated Criteria I.E. by adding “or other hematologic malignancies” and changing ≤ 18 years old to ≤ 21 years old
- Updated verbiage in Criteria I.F to state “Tumors/cancers that can be treated with any other type of radiation in members/enrollees with a known genetic mutation/syndrome”
- Updated verbiage in Criteria I.G. to include malignant and benign primary CNS tumors, excluding IDH wild-type glioblastoma (GBM)
- Added clarifying language to Criteria I.J. and removed additional language regarding when normal tissue constraints cannot be met be met by photon-based therapy
- Added cancers of the nasopharynx and nasal cavity to Criteria I.J
- Removed “i.e., preoperative treatment of resectable disease or primary treatment for those with unresectable disease” in Criteria I.K
- Combined previous Criteria I.N. regarding thymomas and thymic carcinoma with Criteria I.M. regarding primary tumors of the mediastinum
- Added Criteria I.O. for malignant pleural mesothelioma
- Added Criteria I.P. for primary malignant or benign bone tumors
- Added Criteria I.Q. for medically inoperable patients with a diagnosis of cancer typically treated with surgery where dose escalation is required due to the inability to receive surgery
- Added Criteria I.R. for primary and metastatic tumors requiring craniospinal irradiation
- Added Criteria I.S. for primary cancers of the esophagus
- Added Criteria I.T. for advanced and unresectable pelvic tumors with significant pelvic and/or peri-aortic nodal disease
- Added Criteria I.U. for members/enrollees with a single kidney or transplanted pelvic kidney with treatment of an adjacent target volume and in whom maximal avoidance of the organ is critical
- Added Criteria I.V. for salivary gland tumors
|
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 HealthPlan Prior Authorization department at 1-800-218-7508.
