News

Effective May 31, 2022: Clinical Policies

Date: 03/17/22

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 May 31, 2022, at 12:00AM.

POLICY	APPLICABLE PRODUCTS	NEW POLICY OVERVIEW OR UPDATED POLICY REVISIONS
Implantable Intrathecal or Epidural Pain Pump (CP.MP.173)	Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP, and Ambetter	Policy updates include: In I. added “epidural or” intrathecal administration In I.A.1. added Inadequate response “to or intolerable side effects from” In II.A added: When “the above criteria for” the preliminary trial is met “and the following: Body size is sufficient to support the weight and bulk of the device; No other implanted programmable devices for which the interaction between devices may inadvertently change the prescription; No known allergy or hypersensitivity to the drug being used” added “Note: The trial requirement for a percutaneous intrathecal or epidural drug delivery system for pain of malignant origin may be reviewed on a case-by-case basis for instances of advanced disease, when survival time is limited, or considered high risk for procedures” In II.B added “when the above criteria for the preliminary trial is met and all of the following” Removed duplicate criteria from II.B “no active infection” Updated policy title from "Implantable Intrathecal Pain Pump" to “Implantable Intrathecal or Epidural Pain Pump"
Transcranial Magnetic Stimulation for Treatment Resistant Major Depression (CP.BH.200)	Ambetter	Policy updates include: In Policy/Criteria: Section I: initial sessions revised from 30 to 20 Section II: additional sessions revised from 20 to 10

POLICY

APPLICABLE PRODUCTS

NEW POLICY OVERVIEW OR UPDATED POLICY REVISIONS

Implantable Intrathecal or Epidural Pain Pump

(CP.MP.173)

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

Policy updates include:

In I. added “epidural or” intrathecal administration
In I.A.1. added Inadequate response “to or intolerable side effects from”
In II.A added:
- When “the above criteria for” the preliminary trial is met “and the following: Body size is sufficient to support the weight and bulk of the device; No other implanted programmable devices for which the interaction between devices may inadvertently change the prescription; No known allergy or hypersensitivity to the drug being used”
- added “Note: The trial requirement for a percutaneous intrathecal or epidural drug delivery system for pain of malignant origin may be reviewed on a case-by-case basis for instances of advanced disease, when survival time is limited, or considered high risk for procedures”
In II.B added “when the above criteria for the preliminary trial is met and all of the following”
Removed duplicate criteria from II.B “no active infection”
Updated policy title from "Implantable Intrathecal Pain Pump" to “Implantable Intrathecal or Epidural Pain Pump"

Transcranial Magnetic Stimulation for Treatment Resistant Major Depression

(CP.BH.200)

Ambetter

Policy updates include:

In Policy/Criteria:
- Section I: initial sessions revised from 30 to 20
- Section II: additional sessions revised from 20 to 10

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.