Effective September 23, 2024: Clinical Policies

Date: 09/23/24

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 September 23, 2024, 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

Cosmetic and Reconstructive Procedures

(CP.MP.31)

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

Policy updates include:

Added note to see MC.CP.MP.31 for Medicare health plans
Updated criteria numbering so that I.A.2.a. is now I.A.3
Added criteria to I.A.2. to include in an area that affects eyesight
Under I.A.3. replaced “standard” with “conservative
Moved notes about health plan-adopted nationally recognized decision support criteria and gender dysphoria to Description
Removed note regarding prophylactic mastectomy with BRCA mutation

Diaphragmatic/Phrenic Nerve Stimulation

(CP.MP.203)

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

Policy updates include:

Criteria I. updated to include the Spirit Diaphragm Pacing Transmitter
Background updated to include information regarding full FDA approval of the Spirit Diaphragm Pacing Transmitter

Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea

(CP.MP.180)

Ambetter

Policy updates include:

Added criteria II. regarding drug induced sleep endoscopy (DISE) being medically necessary when completed to evaluate the appropriateness of a hypoglossal nerve stimulation device
CPT code “42975” added

Orthognathic Surgery

(CP.MP.202)

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

Policy updates include:

Updated Criteria I.A.1.b. from greater than 4 mm to 4 mm or greater
Updated Criteria I.A.2.c. to include irritation of buccal or lingual soft tissues of the opposing arch
Added clarifying language to Criteria I.A.3.b

Posterior Tibial Nerve Stimulation for Voiding Dysfunction

(CP.MP.133)

Ambetter

Policy updates include:

Updated criteria under I.B. by replacing anti-muscarinics or β3-adrenoceptor agonists and/or antibiotics for urinary tract infections with medications used with the intent to treat OAB

Selective Nerve Root Blocks and Transforaminal Epidural Steroid Injections

(CP.MP.165)

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

Policy updates include:

Changed duration from six weeks to four weeks in I.B.4.a. and c. and II.B.5.a. and c
Added Table 1 to give examples of particulate and non-particulate steroids

Skilled Nursing Visits

(TX.CP.MP.538)

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

Policy updates include:

Added note to III. B. 2 “Note: One as needed (PRN) SNV visit may be approved every 30 days in addition to the medically necessary visits when SNV request has been approved”

Therapeutic Utilization of Inhaled Nitric Oxide

(CP.MP.87)

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

Policy updates include:

Corrected May revision log entry to include:
- removed criteria I.A., “iNO will be administered via endotracheal tube or tracheostomy”
- updated oxygen index from ≥ 25 to > 20 in criteria I.A.6
Added additional indication I.B.1.a.3) right ventricular failure

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.