News

Effective May 31, 2021: Clinical Policies

Date: 03/31/21

Superior HealthPlan has either created new policy, revised or retired existing 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 have been created, revised or retired:

Policy	Applicable Products	New Policy Overview, Policy Revisions or Policy Retired:
Diaphragmatic/Phrenic Nerve Stimulation CP.MP.203	Medicaid, Ambetter, and CHIP	Policy revisions include: Integrated diaphragmatic pacing criteria from CP.MP.107 DME and Legacy WellCare Diaphragmatic Phrenic Nerve Stimulation HS-185 policy Removed ICD-10-PCS codes and replaced with ICD-10-CM codes Separated criteria by FDA approved device Added medical necessity criteria for amyotrophic lateral sclerosis (ALS), additional verbiage changes made with no clinical significance
Durable Medical Equipment and Orthotics and Prosthetics Guidelines CP.MP.107	Medicaid, Ambetter, and CHIP	Policy revisions include: Added note to the description stating that if a lower cost, medically necessary item exists and will meet the member’s needs, the lower cost item will be approved Updated policy to remove diaphragmatic nerve stimulation criteria, which was transferred to CP.MP.203 Diaphragmatic Phrenic Nerve Stimulation Nebulizer, ultrasonic: changed to not medically necessary with supporting statement Blood glucose monitor with integrated voice synthesizer: revised language from diabetics to member/enrollee with diabetes Implantable infusion pumps: Added contraindications Gastric suction pump: added requirement of inability to empty gastric secretions through normal gastrointestinal functions Wheelchair criteria added to its own table Criteria for manual added and coding updated Direction added to use nationally recognized criteria for upper extremities and myoelectric prosthetics Split lower extremity prosthetics into its own row Removed codes from shoulder, elbow, wrist, hand, finger orthotics that were duplicated in IQ, L3720, L3730, L3740, L3760, L3900, L3901, L3960, L3962 and L3999 Updated table of contents
Obstetrical Home Care Programs CP.MP.91	Medicaid, Ambetter, and CHIP	Policy revisions include: Removed reference to OptionCare in description In C. Hydration therapy, changed initial course and additional course of up to 14 visits to up to 7 visits at a time In D. Diabetes in pregnancy, removed the word “program” from the title and criteria; deleted all criteria except the requirement for diagnosis of type 2 DM, or gestational diabetes, and specified that both are non-insulin dependent; deleted reference to case rate, and added that 1 visit is medically necessary Combined criteria in E. for insulin injections and F. for insulin pump into E; removed criteria except for being pregnant and requiring insulin administration; changed number of medically necessary visits from 14 to up to 7 days for the initial and additional courses For hypertensive disorders in pregnancy, replaced “program” in the title with “management;” changed number of medically necessary visits from up to 14 days with an additional 7 if needed to one visit For preeclampsia in pregnancy, replaced “program” with “visits for management;” changed the number of initial and additional medically necessary visits from up to 7 to an additional home visit with phone follow as needed For preterm labor management, changed number of medically necessary visits from 3 in one week to 1 home visit in a week, with additional phone follow up as needed
Pediatric Heart Transplant CP.MP.138	Medicaid, Ambetter, and CHIP	Policy revisions include: Reformatted criteria to group all class C heart failure scenarios together and added additional exclusion of ruling out reversible causes of heart failure

Policy

Applicable Products

New Policy Overview, Policy Revisions or Policy Retired:

Diaphragmatic/Phrenic Nerve Stimulation

CP.MP.203

Medicaid, Ambetter, and CHIP

Policy revisions include:

Integrated diaphragmatic pacing criteria from CP.MP.107 DME and Legacy WellCare Diaphragmatic Phrenic Nerve Stimulation HS-185 policy
Removed ICD-10-PCS codes and replaced with ICD-10-CM codes
Separated criteria by FDA approved device
Added medical necessity criteria for amyotrophic lateral sclerosis (ALS), additional verbiage changes made with no clinical significance

Durable Medical Equipment and Orthotics and Prosthetics Guidelines

CP.MP.107

Medicaid, Ambetter, and CHIP

Policy revisions include:

Added note to the description stating that if a lower cost, medically necessary item exists and will meet the member’s needs, the lower cost item will be approved
Updated policy to remove diaphragmatic nerve stimulation criteria, which was transferred to CP.MP.203 Diaphragmatic Phrenic Nerve Stimulation
Nebulizer, ultrasonic: changed to not medically necessary with supporting statement
Blood glucose monitor with integrated voice synthesizer: revised language from diabetics to member/enrollee with diabetes
Implantable infusion pumps: Added contraindications
Gastric suction pump: added requirement of inability to empty gastric secretions through normal gastrointestinal functions
Wheelchair criteria added to its own table
Criteria for manual added and coding updated
Direction added to use nationally recognized criteria for upper extremities and myoelectric prosthetics
Split lower extremity prosthetics into its own row
Removed codes from shoulder, elbow, wrist, hand, finger orthotics that were duplicated in IQ, L3720, L3730, L3740, L3760, L3900, L3901, L3960, L3962 and L3999
Updated table of contents

Obstetrical Home Care Programs

CP.MP.91

Medicaid, Ambetter, and CHIP

Policy revisions include:

Removed reference to OptionCare in description
In C. Hydration therapy, changed initial course and additional course of up to 14 visits to up to 7 visits at a time
In D. Diabetes in pregnancy, removed the word “program” from the title and criteria; deleted all criteria except the requirement for diagnosis of type 2 DM, or gestational diabetes, and specified that both are non-insulin dependent; deleted reference to case rate, and added that 1 visit is medically necessary
Combined criteria in E. for insulin injections and F. for insulin pump into E; removed criteria except for being pregnant and requiring insulin administration; changed number of medically necessary visits from 14 to up to 7 days for the initial and additional courses
For hypertensive disorders in pregnancy, replaced “program” in the title with “management;” changed number of medically necessary visits from up to 14 days with an additional 7 if needed to one visit
For preeclampsia in pregnancy, replaced “program” with “visits for management;” changed the number of initial and additional medically necessary visits from up to 7 to an additional home visit with phone follow as needed
For preterm labor management, changed number of medically necessary visits from 3 in one week to 1 home visit in a week, with additional phone follow up as needed

Pediatric Heart Transplant

CP.MP.138

Medicaid, Ambetter, and CHIP

Policy revisions include:

Reformatted criteria to group all class C heart failure scenarios together and added additional exclusion of ruling out reversible causes of heart failure

To review all Clinical 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.