Recently Updated Superior Clinical and Payment Policies

Date: 08/31/17

Superior HealthPlan has recently updated our clinical and payment policies for providers that serve the following members:

Ambetter from Superior HealthPlan
CHIP
Medicaid (STAR, STAR+PLUS, STAR Kids and STAR Health)
STAR+PLUS Medicare-Medicaid Plan (MMP)
Superior HealthPlan Medicare Advantage (HMO and HMO SNP)

The following policies have been updated and must be reviewed and followed by Superior providers:

Payment Policies

High Complexity Medical Decision-Making - Payers expect that a provider who bills a high intensity Evaluation and Management (E&M) service is either treating a very ill patient, or the physician was required to review an extensive amount of clinical data to determine the best health management option. To ensure proper reimbursement when billing high intensity E&M codes, providers must show documentation that supports medical necessity and:

An extensive number of diagnoses or management options were reviewed.
An extensive amount and/or complexity of data was reviewed.
There is a high risk of complications and/or morbidity and mortality.

Robotic Surgery - Superior will disallow reimbursement for CPT S2900 for surgical techniques requiring the use of a robotic surgical system. This code is billed along with a primary surgical procedure code, and is an add-on code that denotes separate reimbursement for the robotic technique. The use of a robotic surgical device is a method of performing a surgical procedure and not a requirement of the procedure, nor one that ensures a more successful outcome if a robotic approach had not been used.

Inpatient Only Procedure (Ambetter Only) - The Centers for Medicare and Medicaid Services (CMS) has determined that certain procedures should only be performed in an inpatient setting and therefore, are not appropriate to be conducted in an outpatient facility setting. According to CMS, inpatient only services are generally, but not always, surgical services that require inpatient care due to the nature of the procedure. Patient’s who require this service typically have an underlying physical condition that needs at least 24 hours of postoperative recovery time or monitoring before the patient can be safely discharged.

Clinical Policies

Low-Frequency Ultrasound Therapy for Wound Management - It is the policy of Superior HealthPlan that low-frequency ultrasound wound therapy is considered investigational.

EpiFix Wound Treatment - It is the policy of Superior HealthPlan that Epifix is medically necessary for the treatment of chronic foot ulcers when all of following criteria are met:

Age ≥ 18 years
Type I or Type II diabetes
Foot ulcer surface area* > 1cm²and < 25cm²
Ulcer duration of > 4 weeks, unresponsive to standard wound care
No clinical signs of infection
Ulcer does not probe to tendon, muscle, capsule or bone
Serum creatinine < 3.0 mg/dl
HbA1c < 12%
Adequate circulation to the affected extremity as demonstrated by dorsum transcutaneous oxygen test (TcPO2) > 30mmHg, or ankle-brachial index (ABI) between 0.7 and 1.2 or triphasic or biphasic Doppler arterial waveforms at the ankle of affected leg

Wireless Motility Capsule (WMC) - It is the policy of Superior HealthPlan that WMC is not medically necessary for the evaluation of suspected gastric and intestinal motility disorders, as well as all other indications.

Mechanical Stretching Devices for Joint Stiffness and Contracture - It is the policy of Superior Health Plan that the low-load prolonged-duration stretch (LLPS) device /dynamic stretch device is medically necessary for rehabilitation of extensor tendon injury of the finger; however, the LLPS device for any other indication or any other joint is considered not medically necessary.

To view all of Superior’s clinical and payment policies, please visit the Superior Clinical & Payment Policies web page.

For any questions on these policies, providers may reach out to their local Account Manager, or contact Provider Services at 1-877-391-5921.