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Effective April 30, 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 April 30, 2025, at 12:00AM.

POLICY

APPLICABLE PRODUCTS

NEW POLICY OVERVIEW OR UPDATED POLICY REVISIONS

Durable Medical Equipment and Orthotics and Prosthetics Guidelines

(CP.MP.107)

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

Policy updates include:

  • Replaced codes K1032 and K1033 with E0678 and E0679 under non-pneumatic compression devices
  • Added additional note to enclosed bed section
  • Removed halo procedure and equipment criteria due to no prior auth
  • Removed lumbar sacral orthotics criteria, defer to IQ
  • Updated verbiage and coding in spinal orthotics section
  • Updated criteria under hip orthotics
  • Added section and code L2006 for microprocessor-controlled knee-ankle-foot orthoses (KAFO)
  • Removed code L4130 under shoulder, elbow, wrist, hand, finger orthotics
  • Updated code E2300 to E2298 under power seat elevator on power wheelchair
  • Updated wheelchair repairs section to include wheelchair and other DME repairs

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.