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Effective November 30, 2022: Clinical Policies

Date: 09/21/22

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 November 30, 2022, at 12:00AM.




Gender-Affirming Procedures


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

Policy updates include:

  • Added note before the criteria section stating that individuals with a disorder of sexual development (i.e. intersex) don’t need to meet all the same criteria for duration of gender dysphoria, age requirements and duration of prior treatment such as hormone therapy
  • Incorporated gender-neutral language to the eligibility and criteria section II. A. 1, E. and III. A and B
  • In II.B., noted that informed consent includes awareness of treatment effects on fertility
  • Added the word “minimum” to degree requirement in criteria II.F. and G
  • In II.E, noted that the requirement of 12 months of hormone therapy before mastectomy in adolescents should be considered on a case-by-case basis.
  • Added new criteria in section IV regarding facial procedures
  • Modified the not medically necessary procedures list in VI accordingly

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.