Effective November 7, 2023: Prior Authorization Criteria for Infusion Pumps

Date: 11/02/23

Superior HealthPlan will begin to utilize policy CP.MP.107 Durable Medical Equipment (DME) as the medically necessary review criteria for infusion pumps (E0781) effective November 7, 2023. Superior ensures medical necessity review criteria is current and appropriate for members and the scope of services provided.

Procedure Code	Applicable Products	Criteria
E0781 - Ambulatory Infusion Pump, Multiple Channels	Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP	CP.MP.107 Durable Medical Equipment (DME)

To review prior authorization requirements, please visit Superior’s Authorization Requirements webpage.

For questions or additional information, contact Superior’s Prior Authorization department at 1-800-218-7508.