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Effective September 26, 2022: Clinical Policies

Fecha: 21/09/22

Superior HealthPlan has updated certain 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 26, 2022, 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

Bariatric Surgery

(CP.MP.37)

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

Policy updates include:

  • In Section III, added indication for SG to RYGB or BPD-DS DS as a bridging procedure for BMI ≥ 50 kg/m² in III.4

Reduction Mammoplasty and Gynecomastia Surgery

(CP.MP.51)

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

Policy updates include:

  • Changed “women” to “members/enrollees” in I.A.5.c
  • Added I.B.5. to gigantomastia of pregnancy criteria
  • Language references in the criteria, description and background sections changed from “male” and/or “female” to “those with a male reproductive system” and/or “those with a female reproductive system”

Transcranial Magnetic Stimulation for Treatment Resistant Major Depression

(CP.BH.200)

Ambetter

Policy updates include:

  • In Policy/Criteria Section I, changed the initial number of sessions from 20 to 30 authorizations reviewed on a case-by-case basis
  • Section II.A was changed from an additional 10 to additional 6 sessions of TMS reviewed on a case-by-case basis

Trigger Point Injections for Pain Management

(CP.MP.169)

Ambetter

Policy updates include:

  • In I.B. updated criteria from 2 additional injections to 4
  • In I.B.1 added pain relief with functional improvement
  • In I.B.2. added “≥” 6 weeks
  • In I.B.4:
    • Added “from initial injection”
    • Changed maximum of 4 total sessions to 6

Vagus Nerve Stimulation

(CP.MP.12)

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

Policy updates include:

  • Added opposition to surgery as a possibility
  • Removed “resective” in I.C

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.