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Effective January 31, 2024: Clinical Policies

Fecha: 14/11/23

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 January 31, 2024, 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:
  • Changed Orthopedic Care Equipment to Prosthetics and Orthotics Equipment
  • Retired pneumatic compression device criteria (E0675) for IQ
  • Updated "Cabinet style..." note under Ultraviolet panel lights
  • Under “Other Equipment” added code E0240 to “Specialized supply or equipment” section and added section, criteria, and coding (E1399, A9900) for “ROMTech device”
  • Reformatted Foot orthotics, custom criteria in “Prosthetics and Orthotics Equipment” section
  • Added criteria for Prosthetics and additions: Upper Extremity and Myoelectric in “Prosthetics and Orthotics Equipment” section
  • Added section, criteria, and coding (L8701, L8702) for “MyoPro Orthosis” under “Prosthetics and Orthotics Equipment”
  • Removed code L8035 from "other surgical supplies" and added section and criteria for "Breast Prosthetics" (L8030, L8035)
  • Removed pediatric wheelchair codes (E1229, E1231, E1232, E1233, E1234, E1235, E1236, E1237, E1238, E1037) from manual wheelchair section

 

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.