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Effective October 30, 2020: Clinical Policies

Date: 10/01/20

Superior HealthPlan has revised 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 revised:

POLICY

APPLICABLE PRODUCTS

POLICY REVISIONS

Trigger Point Injections for Pain Management

CP.MP.169

Ambetter

Policy updates include:

  • In Section I. B. 4: Changed maximum of 6 injections/year to 4 injections/year
  • Added ICD-10 code M79.18 and changed M79.1 to M79.12

 

 

Vagus Nerve Stimulation

CP.MP.12

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

 

Policy updates include:

  • Added additional investigational indications for Vagus Nerve Stimulation (VNS) to Section II: E-BB: Addiction, Anxiety Disorders, Autism, Eating Disorders, Cancer, Chron’s Disease, Essential trauma, Fibromyalgia, Heart Failure, Impaired glucose tolerance/pre-diabetes, Inflammation, Overweight and obesity, Obsessive-compulsive disorder, Panic disorder, Post-traumatic stress disorder, Prader-Willi Syndrome, Siogren’s Syndrome, Rheumatoid arthritis, Schizophrenia, Sleep disorders, Stroke, Tinnitus, Tourette’s syndrome, Traumatic brain injury
  • Removed ICD-10 Codes: G40.001, G40.009, G40.201, G40.209, G40.309, G40.A09, G40.409, G40.509, G40.802, G40.909, G40.911 and G40.919
  • Added ICD-10: G40.813, G40.814

 

To review all Clinical policies, please visit Superior’s Clinical 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.