Skip to Main Content

News

Effective July 31, 2025: Clinical Policies

Date: 07/25/25

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, 2025, 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

Bone-Anchored Hearing Aid

(TX.CP.MP.522)

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

Policy updates include:

Table updated to include L8694
Added clarifying language to Section I. B. “where the condition prevents restoration of hearing using a conventional air-conductive hearing aid”
Section I. C. replaced “<70 dB HL” with “is consistent with the FDA indications for the requested device”

Caudal or Interlaminar Epidural Steroid Injections

(CP.MP.164)

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

Policy updates include:

Removed “and the member/enrollee is not currently being treated with full anticoagulation therapy
If on warfarin, international normalized ratio (INR) should be ≤ 1.4 prior to the procedure” from criteria

Facet Joint Interventions

(CP.MP.171)

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

Policy updates include:

Updated Criteria I.A.1.b.i. regarding physical therapy
Note added under Criteria I.A.1.b.i. regarding physical therapy or prescribed home exercise program in the presence of a facet joint synovial cyst
Removed Criteria I.A.1.b.ii. regarding activity modification
Updated Criteria I.A.1.c. to include notation about facet joint synovial cystU

Fetal Surgery in Utero for Prenatally Diagnosed Malformations

(CP.MP.129)

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

Policy updates include:

Removed specific degree requirement for severe kyphosis in Criteria I.G.5.a
Removed previous Criteria I.G.5.d. regarding maternal BMI contraindication
Added clarifying language to Criteria III

NICU Discharge Guidelines

(CP.MP.81)

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

Policy updates include:

Updated normal ambient temperature range in Criteria II.A

Pediatric Liver Transplant

(CP.MP.120)

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

Policy updates include:

Removed “at time of diagnosis” from criteria I.B.5.d. and I.B.5.k
Under I.B.7.c. reformatted criteria with no impact to criteria
Under I.C.4. updated glomerular filtration rate from <40 to < 30

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.