Effective September 30, 2022: Clinical Policies

Date: 07/20/22

Superior HealthPlan has added 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 30, 2022, at 12:00AM.

POLICY	APPLICABLE PRODUCTS	NEW POLICY OVERVIEW OR UPDATED POLICY REVISIONS
Liposuction for Lipedema (CP.MP.244)	Ambetter	New Policy includes: Medical necessity review criteria for liposuction requiring secondary medical director review as it pertains to the treatment of lipedema Outline that liposuction for lipedema for any indications other than the criteria listed are not medically necessary Detailed description of lipedema, how to identify the disease, specific disease characteristics and current effective treatment Coding associated with lipedema treatment services

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.