News

Effective March 28, 2022: Clinical Policies

Date: 03/17/22

Superior HealthPlan has updated certain 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 March 28, 2022, at 12:00AM.

Changes in these policies reflect pre-authorization requirement amendments that are less burdensome to insureds, physicians, or health care providers.

POLICY	APPLICABLE PRODUCTS	NEW POLICY OVERVIEW OR UPDATED POLICY REVISIONS
Radiofrequency Ablation of Uterine Fibroids (CP.MP.187)	Ambetter	Policy updates include: Policy updated with medical necessity criteria for laparoscopic RFA (Acessa). Insufficient evidence statement now only applies to transcervical radiofrequency ablation (Sonata)
Ventricular Assist Devices (CP.MP.46)	Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), and CHIP	Policy updates include: Added “Cardiac Index (CI) <2.2 L/min/m2, while not on inotropes and meet one of the following criteria: No response to optimal medical management, including beta-blockers and ACE inhibitors, if tolerated, for at least 45 out of the last 60 days Presence of advanced heart failure for at least 14 days with dependence on an intra-aortic balloon pump (IABP) or similar temporary mechanical circulatory support for at least 7 days” to Policy/Criteria I.B.4 to reflect update to NCD Ventricular Assist Devices 20.9.1 per CMS

POLICY

APPLICABLE PRODUCTS

NEW POLICY OVERVIEW OR UPDATED POLICY REVISIONS

Radiofrequency Ablation of Uterine Fibroids

(CP.MP.187)

Ambetter

Policy updates include:

Policy updated with medical necessity criteria for laparoscopic RFA (Acessa). Insufficient evidence statement now only applies to transcervical radiofrequency ablation (Sonata)

Ventricular Assist Devices

(CP.MP.46)

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

Policy updates include:

Added “Cardiac Index (CI) <2.2 L/min/m2, while not on inotropes and meet one of the following criteria:
- No response to optimal medical management, including beta-blockers and ACE inhibitors, if tolerated, for at least 45 out of the last 60 days
- Presence of advanced heart failure for at least 14 days with dependence on an intra-aortic balloon pump (IABP) or similar temporary mechanical circulatory support for at least 7 days” to Policy/Criteria I.B.4 to reflect update to NCD Ventricular Assist Devices 20.9.1 per CMS

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 HealthPlan Prior Authorization department at 1-800-218-7508.