News

Effective July 31, 2024: Clinical Policies

Date: 05/24/24

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 July 31, 2024, at 12:00AM.

POLICY	APPLICABLE PRODUCTS	NEW POLICY OVERVIEW OR UPDATED POLICY REVISIONS
Deep Transcranial Magnetic Stimulation for the Treatment of Obsessive Compulsive Disorder (CP.BH.201)	Ambetter	Policy updates include: Separated former criteria point I.A into two sub points (A and B) Criteria point I. D. reworded for clarity “Direct supervision of treatment is provided by a licensed psychiatrist except where state scope of practice acts allows for other provider types to supervise” Removed I.H.3. “Vagus nerve stimulator leads in the carotid sheath” as this is captured in I.H.2.h In criteria point I.H.4. replaced “substance abuse at time of treatment” with “less than three months of substantiated remission from a substance use disorder” Removed “Neurological disease or head injury” and “pregnancy” from the contraindication list Added new CPT/HCPCS codes: “97014: Application of a modality to 1 or more areas; electrical stimulation (unattended); 97032: Application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes
Transcranial Magnetic Stimulation for Treatment Resistant Major Depression (CP.BH.200)	Ambetter	Policy updates include: Criteria point I.D. added that the pre-TMS score should be documented in order to measure progress more effectively “Planned use of a depression severity standardized rating scale by the TMS provider to monitor response during treatment, “with pre-TMS score documented” Removed prior criterion I.G. and reworded criteria regarding trial and failure of psychopharmacologic therapy and psychotherapy in new I.G and I.H. to include the requirement for a standardized scale to indicate moderate to severe depression throughout treatment In I.G., clarified that the member/enrollee must present with the “failure or intolerance to two trials of psychopharmacologic agents from at least two different agent classes” In I.G.2, required that both criteria a and b be met for intolerance In G.2.b, specified that “at least 4 antidepressants representing at least 2 different drug classes” must have been attempted In I.H., added a note that the therapy should overlap with medication trials In I.J., added contraindication “concomitant esketamine intranasal, ketamine infusion, or other infusion therapies” Removed HCPCS coding table including G0295

POLICY

APPLICABLE PRODUCTS

NEW POLICY OVERVIEW OR UPDATED POLICY REVISIONS

Deep Transcranial Magnetic Stimulation for the Treatment of Obsessive Compulsive Disorder

(CP.BH.201)

Ambetter

Policy updates include:

Separated former criteria point I.A into two sub points (A and B)
Criteria point I. D. reworded for clarity “Direct supervision of treatment is provided by a licensed psychiatrist except where state scope of practice acts allows for other provider types to supervise”
Removed I.H.3. “Vagus nerve stimulator leads in the carotid sheath” as this is captured in I.H.2.h
In criteria point I.H.4. replaced “substance abuse at time of treatment” with “less than three months of substantiated remission from a substance use disorder”
Removed “Neurological disease or head injury” and “pregnancy” from the contraindication list
Added new CPT/HCPCS codes: “97014: Application of a modality to 1 or more areas; electrical stimulation (unattended); 97032: Application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes

Transcranial Magnetic Stimulation for Treatment Resistant Major Depression

(CP.BH.200)

Ambetter

Policy updates include:

Criteria point I.D. added that the pre-TMS score should be documented in order to measure progress more effectively “Planned use of a depression severity standardized rating scale by the TMS provider to monitor response during treatment, “with pre-TMS score documented”
Removed prior criterion I.G. and reworded criteria regarding trial and failure of psychopharmacologic therapy and psychotherapy in new I.G and I.H. to include the requirement for a standardized scale to indicate moderate to severe depression throughout treatment
In I.G., clarified that the member/enrollee must present with the “failure or intolerance to two trials of psychopharmacologic agents from at least two different agent classes”
In I.G.2, required that both criteria a and b be met for intolerance
In G.2.b, specified that “at least 4 antidepressants representing at least 2 different drug classes” must have been attempted
In I.H., added a note that the therapy should overlap with medication trials
In I.J., added contraindication “concomitant esketamine intranasal, ketamine infusion, or other infusion therapies”
Removed HCPCS coding table including G0295

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’s Prior Authorization department at 1-800-218-7508.