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Effective March 31, 2025: Clinical Policies

Date: 03/26/25

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.

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

Bariatric Surgery

(CP.MP.37)

Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS)

Policy updates include:

  • Added I.A.1.a.xvi Atrial fibrillation
  • Added I.A.1.a.xvii. Heart failure
  • Removed previous preoperative evaluation and medical clearance requirements in I.B. and I.C. and replaced with consolidated requirements I.B.1. through 3

Gastric Electrical Stimulation

(CP.MP.40)

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

Policy updates include:

  • Changed I.C. to “Chronic intractable (drug refractory) nausea and vomiting”
  • Revised verbiage in note at the end of policy/criteria
  • Added L8685, L8686, and L8687 and their respective descriptions to HCPCS code table

 

NICU Apnea Bradycardia Guidelines

(CP.MP.82)

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

Policy updates include:

  • Replaced “Guidelines” section title with “Policy/Criteria” title and added verbiage regarding health plans affiliated with Centene Corporation®
  • Updated Criteria I.A.1. to include desaturation as a clinically significant cardiorespiratory event and updated criteria verbiage for clarity
  • Removed notation in Criteria I.A.1.b. regarding consideration of using heart rate decrease > 33.3% below baseline for older, more mature infants or those with a lower baseline heart rate
  • Updated Criteria I.A.1.d. from bradycardia to isolated bradycardia and updated from < 70 beats per minute to < 80 beats per minute
  • Minor rewording for clarity in Criteria I.B. and Criteria I.D
  • Updated Note at end of criteria section to state caffeine levels may be therapeutic in preterm infants for as long as ten days after discontinuation
  • Removed statement in Note section regarding “caffeine countdown”
  • Added car bed and added clarifying language to Note section regarding assessment of cardiorespiratory stability in a car seat

 

NICU Discharge Guidelines

(CP.MP.81)

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

Policy updates include:

  • Updated Authorization protocol A.5. Apnea or bradycardia monitoring with last dose of caffeine at least seven days prior to discharge
  • Updated NICU DC recommended practices B.4. An assessment of cardiorespiratory stability in a car seat or car bed is recommended prior to discharge for infants born at < 37 weeks gestation or for infants with other risk factors for cardiorespiratory compromise (e.g. neuromuscular, orthopedic problems)
  • Updated E.1. to reflect car bed recommendations

 

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.