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Effective May 31, 2024: Clinical Policies

Date: 03/20/24

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 May 31, 2024, at 12:00AM.

POLICY

APPLICABLE PRODUCTS

NEW POLICY OVERVIEW OR UPDATED POLICY REVISIONS

Gastric Electrical Stimulation

(CP.MP.40)

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

Policy updates include:

  • Added I.A. "Member/enrollee is ≥ 18 years of age"
  • Updated I.B. to include "diabetic or" in describing type of gastroparesis
  • Updates made to CPT code descriptions

Implantable Intrathecal or Epidural Pain Pump (CP.MP.173)

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

Policy updates include:

  • Restructured and reformatted criteria section
  • In I.B. and II.B. added contraindications to include known allergies to materials in the implant;
  • Active alcohol or drug abuse, including but not limited to:
    • Opioid addiction and intravenous drug abuse
    • Diagnosis of dementia or psychosis
    • Active systemic infection
    • Active infection at the site of implantation

Outpatient Oxygen Use (CP.MP.190)

CHIP, and Ambetter

Policy updates include:

  • Updated all criteria instances of "blood gas study" to include "or pulse oximetry measurement" and all instances of “arterial oxygen saturation” to include “(or pulse oximetry)”
  • Changed age requirements in I. and III. from ≥ 21 to ≥ 18 years of age
  • Changed age requirements in II and IV from <21 to <18 years of age
  • Added clarifying language to Criteria I.B.1.a. regarding breathing room air
  • In I. B.1.b., I.B.1.c., and I.B.2.a., removed the requirement that the measurement is taken after 5 minutes of sleep vs. during sleep
  • Criteria I.D.2. updated to reflect condition requirements for blood gas study not performed during an inpatient hospital stay
  • Removed I.E. regarding alternative treatments
  • Added clarifying language to Criteria II.A.2. for cystic fibrosis complicated by severe chronic hypoxemia
  • Updated Criteria II.A.4. to state Bronchopulmonary dysplasia (BPD) complicated by chronic hypoxemia
  • Added Criteria II.A.9. to include pulmonary hypertension without congenital heart disease complicated by chronic hypoxemia
  • Added Criteria II.A.10. to include interstitial lung disease complicated by severe chronic hypoxemia
  • Updated Criteria II.B.1. and Criteria II.B.2. to include requirements for SpO2 measurements for children younger than one year old and for children aged one year or older
  • Clarifying language added to Criteria V.C. regarding the absence of systemic hypoxemia
  • Added Criteria V.E. to include terminal illnesses that do not affect the ability to breathe
  • Added Criteria VI.A.3. to include frequency of headache attacks

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.