News
Effective October 1, 2021: Prior Authorization Change
Date: 07/27/21
Effective October 1, 2021, Ambetter from Superior HealthPlan will require prior authorization for certain codes related to medical implanted devices and stereotactic radiosurgery. Ambetter will utilize applicable clinical policies as the medical necessity review criteria for these services. To review all policies, please visit Superior’s Clinical, Payment & Pharmacy Policies webpage.
Superior ensures medical necessity review criteria is current and appropriate for members and the scope of services provided. The following codes are those impacted by this change.
CPT Codes | Description |
|---|---|
54401 | Insertion of penile prosthesis; inflatable (self-contained) |
54405 | Insertion of multi-component, inflatable penile prosthesis, including placement of pump, cylinders, and reservoir |
61885 | Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array |
61886 | Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to 2 or more electrode arrays |
64568 | Incision for implantation of cranial nerve (eg, vagus nerve) neurostimulator electrode array and pulse generator |
69714 | Implantation, osseointegrated implant, temporal bone, with percutaneous attachment to external speech processor/cochlear stimulator; without mastoidectomy |
77371 | Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of 1 session; multi-source Cobalt 60 based |
Prior to updates, 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.