News
Effective April 1, 2021: Clinical Policies
Date:
03/05/21
Superior HealthPlan has either created new policy, revised or retired existing 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 have been created, revised or retired:
Policy
| Applicable Products
| New Policy Overview, Policy Revisions or Policy Retired:
|
|---|
Oxygen Use and Concentrators
CP.MP.190
| CHIP and Ambetter
| Policy revisions include:
- For reauthorization of oxygen concentrators and stationary oxygen systems in adults in section III, added an option for a letter of medical necessity documenting a chronic condition not expected to improve or expected to worsen, when provided in addition to a physician evaluation within 90 days
- Clarified that both the Group 1 re-auth criteria in section III.A.2.a need to be met
- Restructured section III with minor rewording
- Specified that section I. applies to oxygen concentrators and stationary oxygen systems for indications other than cluster headaches, and referred to section VII for stationary oxygen systems for cluster headaches
- Specified in section VII that the criteria for cluster headaches applies to those ≥ 21 years
|
Proton and Neutron Beam Therapies
CP.MP.70
| Ambetter
| Policy revisions include:
- Removed Esophageal and Esophagogastric Junction Cancers as an indication for PBT
- Added Hodgkin Lymphoma, Thymomas and Thymic carcinoma as indications
- Added language for clarity to section I. L “when normal tissue constraints cannot be met with photon therapy (including three dimensional and IMRT techniques); or”
- Clarified section I.M “Non-Small Cell Lung Cancer, to spare critical structures when critical organ dose constraints cannot be met with photon therapy (including three dimensional and IMRT techniques); or”
- ICD -10 Code updates:
- Removed C15.3-C15.9, added C37
- Revised description of codes C71.0-C71.9 and C72.0-C72.9
- Revised code set C79.4-C79.49 - C79.40 to C79.40-C79.49
- Expanded code set C82.00-C96.9 to C81.00-C96.9 and revised description
- Removed “member” from I.F and replaced all other instances of “member” with “member/enrollee”
- Changed title to Proton and Neutron Beam Therapies
|
To review all Clinical 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.
