Clinical Review Criteria – April 2020
Posted on May 4, 2020
Health New England’s Clinical Policies have been updated and can be found at healthnewengland.org/providers/resources. Once on the Resources page, click on Behavioral Health/Medical Policies to learn of the changes.
Effective 6/1/2020
Chondrocyte Transplant to the Knee
• Added 4 definitions
• Updated criteria “For Approval” with adds, deletes and clarifications
• Updated “What is Not Covered”
• Under CPT Codes: Eliminated “*Covered if selection criteria are met:”
Radiofrequency Ablation
• Added definitions
• Added under “Criteria for Approval”
• Updated “What is Not Covered”
• Adjusted codes:
o Deleted all ICD-10 codes
o Added 64999 Unlisted procedure, nervous system (Code is used for pulsed RFA that is NOT covered under HNE plan.)
Blepharoplasty and Browplasty
• Added 4 new definitions
• Updated “Criteria for Approval”
• Under CPT Codes: Removed 67909
Spinal Cord Stimulation
• Added 6 new definitions
• Updated “Criteria for Approval”
• Under CPT Codes: Title changed to be “CPT Codes Configured to Require PA”
• Under HCPCS Codes: Title changed to be “HCPCS Codes Configured to Require PA”
Female Reduction Mammoplasty
• Under definitions: Tanner stages has been added
• Updated “Criteria for Approval”
• Updated “What is Not Covered”
• Adjusted codes: Eliminated ICD-10 codes
Therapeutic Shoe and Orthotic Coverage
• Northwood, Inc., manages DME requests. This policy refers providers to links to the Northwood site.
Formula and Enteral Nutrition
• Northwood, Inc., manages Formula and Enteral Nutrition requests. This policy refers providers to the link to the Northwood site.
Speech Therapy for Autism Disorders
• Updated “Coverage Guidelines”
• Updated “Required Documentation”
• Updated “Limitations”
• Eliminated “**** For Speech Generating Devices refer to policy on HNE’s medical policy website ****”
Photochemotherapy (PUVA), Phototherapy, Laser Treatments
• Updated “Definitions”
• Updated “Criteria for Approval”
• Updated “What is Not Covered”
• Updated CPT Codes:
o Added to statement: “PA Required After 36 Visits for Below CPT Codes”
• Under CPT codes for laser treatments, added: “PA After 36 Visits, Effective 7/1/2020”
Preimplantation Genetic Testing (PGT)/Preimplantation Genetic Diagnosis (PGD)
• Added 3 new definitions
Long-Term 30-Day Cardiac Monitoring
• Health New England has adopted InterQual criteria.
• HNE Nurse Reviewers use InterQual through Medecision’s Aerial Medical Management System.
• InterQual criteria is available upon request by members and providers.
*Please note new/revised policies may not appear until closer to the effective date.
