Clinical Review Criteria
Posted on November 1, 2023
Health New England reviews clinical policies and updates accordingly. These policies reside at healthnewengland.org/Providers/Resources. Once on the Resources page, click on Behavioral Health/Medical Policies to learn more.
Cosmetic and Reconstructive Procedures:
- Coding guidance updated. CPT 15847 not covered for all lines of business.
Knee Braces: Clarification
- HNE’s policy is retired as of 11/1. Please refer to our Durable Medical Benefit Manager’s (Northwood) policy for criteria.
Ambulatory Cardiac Monitoring: Effective 1/1/2024
- PA required for an implantable cardiac monitor
Insertion of Wireless Pulmonary Artery Pressure Sensor & Monitoring (i.e., CardioMEMS):
- added section C
Breast Surgery: Clarification
- Section V (Risk-Reducing (Prophylactic) Mastectomy), removed “Inflammatory Breast
Cancer”
Bone Grafts for Spinal Defects: Clarification
- removed PA for 20930 for MassHealth and Medicare Advantage due this being a nonpayable code for these plans
For more information, please do not hesitate to call your Provider Relations Representative at (800) 842-4464, extension 5000, or send an email to providerrelations@hne.com.
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