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Effective September 15, 2025: Clinical Policies

Date: 07/16/25

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 September 15, 2025, at 12:00AM.

POLICY

APPLICABLE PRODUCTS

NEW POLICY OVERVIEW OR UPDATED POLICY REVISIONS

Allogeneic Hematopoietic Progenitor Cell Therapy

(CP.MP.249)

Ambetter

Policy updates include:

  • Removed Omisirge specific language from title of policy due to expanding policy
  • Updated Description of policy to include RegeneCyte and updated title in the Note referencing the Medicare version of policy
  • Added Criteria II. to include medically necessary criteria for RegeneCyte
  • Background updated to include RegeneCyte information to align with updated criteria

Fecal Incontinence Treatments

(CP.MP.137)

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

Policy updates include:

  • Added criteria I.B.1.d. Member/enrollee demonstrates the ability to operate the device or has a supportive caregiver who could otherwise provide assistance
  • Removed I.B.1.e.iii. Inadequate response to test stimulation or inability to operate the device
  • Removed I.B.3.d. Absence of any physical or mental illness that would increase surgical risk
  • Removed previous criteria I.B.2. for sphincteroplasty
  • Added CPT 44320 and HCPCS C1767, C1778 to coding tables

Reduction Mammoplasty and Gynecomastia Surgery

(CP.MP.51)

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

Policy updates include:

  • Added clarifying language to Criteria I.A
  • Removed “persistent” and “for at least one year” in Criteria I.A.3
  • Added clarifying language to Criteria I.A.3.c. regarding breast pain
  • Added clarifying language regarding inframammary folds in Criteria I.A.3.g
  • Removed criteria II.A.4. requiring adult testicular size to be attained

Skin and Soft Tissue Substitutes for Chronic Wounds

(CP.MP.185)

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

Policy updates include:

  • Added the following codes to the “HCPCS codes that do not support medical necessity criteria” table: A2026, A2027, A2028, A2029, C8002, Q4280, Q4311, Q4312, Q4313, Q4314, Q4315, Q4316, Q4317, Q4318, Q4319, Q4320, Q4321, Q4322, Q4323, Q4324, Q4325, Q4326, Q4327, Q4328, Q4329, Q4330, Q4331, Q4332, Q4333, Q4334, Q4335, Q4336, Q4337, Q4338, Q4339, Q4340, Q4341, Q4342, Q4343, Q4344, Q4345, Q4346, Q4347, Q4348, Q4349, Q4350, Q4351, Q4352, Q4353, Q4368, Q4369, Q4370, Q4371, Q4372, Q4373, Q4375, Q4376, Q4377, Q4378, Q4379, Q4380, Q4382

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.