News

Effective April 5, 2021: Clinical Policies

Date: 03/31/21

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:
Hyperhidrosis Treatments CP.MP.62	Ambetter	Policy revisions include: Combined criteria points in II. H. and III. C to read “failed one of the following: 1 Iontophoresis or 2 Trial of botulinum toxin”
Ventricular Assist Devices CP.MP.46	Medicaid, Ambetter, and CHIP	Policy revisions include: Removed ICD-10 code Z94.1 and added Z76.82 Removed mention of Berlin Heart EXCOR Pediatric VAD under II.A as other pediatric VAD's are being approved Added "if FDA approved or approved under the FDA HDE guidelines and used in accordance with the device specific inclusion/exclusion criteria, including body size." to II Added "or age specific to FDA approved guidelines” to II.A.1 Changed II.A.3 from "Is a candidate for heart transplant" to "As a bridge to heart transplant" Revised description of CPT-33990, 33991 and 33992

Policy

Applicable Products

New Policy Overview, Policy Revisions or Policy Retired:

Hyperhidrosis Treatments

CP.MP.62

Ambetter

Policy revisions include:

Combined criteria points in II. H. and III. C to read “failed one of the following:
- 1 Iontophoresis or
- 2 Trial of botulinum toxin”

Ventricular Assist Devices

CP.MP.46

Medicaid, Ambetter, and CHIP

Policy revisions include:

Removed ICD-10 code Z94.1 and added Z76.82
Removed mention of Berlin Heart EXCOR Pediatric VAD under II.A as other pediatric VAD's are being approved
Added "if FDA approved or approved under the FDA HDE guidelines and used in accordance with the device specific inclusion/exclusion criteria, including body size." to II
Added "or age specific to FDA approved guidelines” to II.A.1
Changed II.A.3 from "Is a candidate for heart transplant" to "As a bridge to heart transplant"
Revised description of CPT-33990, 33991 and 33992

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.