Clinical Review Criteria – December 2020
Posted on December 14, 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.
Please note, new/revised policies may not appear until closer to the effective date.
Reviewed and Updated (Effective date of 2/1/2021 )
Chimeric Antigen Receptor T-Cell Therapy (CAR-T Cell Therapy): Kymriah and Yescarta
• Expanded definition on Kymriah and Yescarta
• Updated “Criteria for Approval”
Bronchial Thermoplasty
• Updated “Criteria for Approval”
• Updated “What is Not Covered”
Artificial Intervertebral Cervical Disc
• Changed medical criteria disclaimer to InterQual disclaimer
• Updated “Criteria for Approval”
• Removed “What is Not Covered/Contraindicated”
• Updated CPT Codes:
– Removed CPT codes 22861 and 22864
Drug Testing
• Under “Scope,” Behavioral Health (BH) was added
• Updated definitions
• Updated “Criteria For Approval of Urine Drug Testing”
• Updated “What is Not Covered”
Gastric Electrical Stimulation (GES) (Enterra Therapy System)
• Updated Section II., “For Continuation of Treatment of somatostatin receptor-positive gastroenteropancreatic neuroendocrine tumors …”
o Added the underlined to the statement:
For Continuation of Treatment of somatostatin receptor-positive gastroenteropancreatic neuroendocrine tumors (GEP-NETs), must meet above criteria and criteria listed below and is limited to
4 doses administered no less than 8 weeks apart.
• Letter A. was added along with 1. through 5.:
o Patient must also meet the following criteria for continuation of treatment:
-No recurrent grade 2, 3, or 4 thrombocytopenia
-No recurrent grade 3 or 4 anemia and neutropenia
-No recurrent hepatotoxicity
-No recurrent grade 3 or 4 non-hematologic toxicity
-Renal toxicity requiring a treatment delay of 4 months or longer
• Updated “What is Not Covered/Contraindications”
B.: Changed the creatinine clearance from < 50 ml/minute to < 30 ml/minute
Skin and Soft Tissue Substitutes
• Updated III., Non-Covered Codes (Experimental and Investigational)
Q4165 and Q4166 were corrected.
Sacral Nerve Stimulation and Electrical Percutaneous Tibial Nerve Stimulation
• Updated definitions
• Updated “Criteria for Approval”
• Updated IV., Contraindications for PTNS include ANY of the following:
Added letter C.: Member with neurogenic overactive bladder syndrome/neurogenic lower urinary tract dysfunction; OR
• Updated CPT Codes:
o Added 64566 Posterior tibial neurostimulation, percutaneous needle electrode, single treatment, includes programming
o Added 4 E & I codes including descriptions
Home Health Care Services for MassHealth
• Updated “Criteria for Approval”
• Updated II., Applicable Codes
Applicable codes moved up into policy under Section II.
Corneal Cross Linking
• Updated “Definitions”
• I., For Commercial Policies only:
A.: Added the underlined: “Progressive keratoconus diagnosed by keratometry and corneal mapping”
• Updated “Criteria for Approval”
• Updated “What is not Covered”
Outpatient Physical and Occupational Therapy
• Updated “Definitions”
• Updated “Criteria for Approval”
• Medicare Advantage Plans, 2.:
o Added the underlined:
For rehabilitation services in a skilled nursing facility (SNF), the evaluation and treatment plan must be submitted along with the prior authorization request. An authorization is required for any
services in an SNF. Member must be showing progress with rehabilitation in order to continue with therapy. Generally, the rehabilitation services are provided 2-3x/week to be considered under Medicare Part B.
o Added CMS link to coverage database
Medicaid Plans:
o Added MassHealth links for PT and OT
o 2.: Added the underlined word:
For rehabilitation services in a skilled nursing facility (SNF), the evaluation and treatment plan must be submitted along with the prior authorization request. An authorization is required for any services in an SNF. Member must be showing progress with rehabilitation in order to continue with therapy.
• Updated “Coverage Guidelines”
• Updated “Required Documentation”
• Updated “What is Not Covered”
Upper Airway Stimulation Device (UAS)/Hypoglossal Nerve Stimulation (HGNS) (Inspire)
• Updated “Criteria for Approval” for Commercial members
Reviewed with no or substantive changes (Effective date of 2/1/2021)
• Knee Arthroplasty and Knee Arthroscopy for MassHealth
• Family Stabilization Team
• New Medical Policies (Effective date of 2/1/2021)
• Non-Covered, Experimental and Investigational Services
• Water Vapor Thermal Therapy (Rezum)
• Antibody Testing for Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) [Coronavirus Disease (COVID-19)]
