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Effective October 31, 2024: Clinical Policies

Date: 07/18/24

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 October 31, 2024, at 12:00AM.

POLICYAPPLICABLE PRODUCTSNEW POLICY OVERVIEW OR UPDATED POLICY REVISIONS
Durable Medical Equipment and Orthotics and Prosthetics Guidelines
(CP.MP.107)		Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter

Policy updates include:

  • Updated verbiage in Newborn Care Equipment, Breast Pumps for inclusivity
  • Added new criteria section titled Lumbar-Sacral Orthotics (LSO) and included codes L0450, L0452, L0454, L0455, L0456, L0457, L0458, L0460, L0462, L0464, L0466, L0467, L0468, L0469, L0470, L0472, L0480, L0482, L0484, L0486, L0488,  L0490, L0491, L0492, L0621, L0622, L0623, L0624, L0625, L0626, L0627, L0628, L0629, L0630, L0631, L0632, L0633, L0634, L0635, L0636, L0637, L0638, L0639, L0640, L0643, L0648, L0649, L0650, L0651, L0700, L0710, L0999, L1000, L1001, L1005
  • Renamed original “Spinal Orthotics” criteria “Other Spinal Orthotics”
  • Updated manual wheelchair initial request criteria A., A.2. and 4., B.1. and 2., and removed C
  • Reformatted and updated manual wheelchair replacement request criteria
  • Deleted codes E1091 and K000


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.