Effective April 15, 2024: Cranial Molding Orthosis

Date: 03/15/24

Superior HealthPlan will utilize Change Healthcare’s InterQual as the medical necessity review criteria of Cranial Molding Orthosis (S1040) for Medicaid and Children’s Health Insurance Program (CHIP) members effective April 15, 2024. Superior ensures medical necessity review criteria is current and appropriate for members and the scope of services provided.

Procedure Code	Applicable Products	Criteria
S1040 - Cranial molding orthosis	Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP	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.