Clinical Review Criteria – February 2021
Posted on February 10, 2021
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 4/1/2021)
Gender Reassignment Surgery
• Updated “Required Documentation”
• Updated “Covered Procedures”
• Updated CPT code per AMA changes
Removed:
19303 Mastectomy, simple, complete
19304 Mastectomy, subcutaneous
Added:
19316 Mastopexy
19318 Breast reduction
19340 Insertion of breast implant on same day of mastectomy (i.e., immediate)
19342 Insertion or replacement of breast implant on separate day from mastectomy
19355 Correction of inverted nipples
19357 Tissue expander placement in breast reconstruction, including subsequent expansion
19361 Breast reconstruction with latissimus dorsi flap
19364 with free flap (e.g., fTRAM, DIEP, SIEA, GAP flap)
19367 with single-pedicled transverse rectus abdominis myocutaneous (TRAM) flap uni25B2
19368 with single-pedicled transverse rectus abdominis myocutaneous (TRAM) flap, requiring separate microvascular anastomosis (supercharging)
19369 with bipedicled transverse rectus abdominis myocutaneous (TRAM) flap
19380 Revision of reconstructed breast (e.g., significant removal of tissue, re-advancement and/or re-inset of flaps in autologous reconstruction or significant capsular revision combined with soft tissue excision in implant-based reconstruction
Changes:
19325 Breast augmentation with implant
19328 Removal of intact breast
19330 Removal of ruptured breast implant, including implant contents (e.g., saline, silicone gel)
19370 Revision of peri-implant capsule, breast, including capsulotomy, capsulorrhaphy, and/or partial capsulectomy
19371 Peri-implant capsulectomy, breast, complete, including removal of all intracapsular contents
Surgical Management of Morbid Obesity
• Updated “Criteria for Approval for Ages 18 and Over”
• Updated “Definitions”
• Updated “Criteria for Approval”
• Updated “What is Not Covered”
Outpatient Hyperbaric Oxygen Therapy
• Updated “Definitions”
• Updated “Criteria for Approval”
Speech Therapy for Autism Disorders
• Updated “Limitations”
Female Breast Reduction
• Changed Policy Title
From: Female Reduction Mammoplasty
To: Female Breast Reduction
• Updated “What is Not Covered”
• Updated “Codes”
Code 19318 description changed to Breast Reduction.
New (Effective date of 4/1/2021)
Transanal Endoscopic Microsurgery (TEMS)
