Clinical Review Criteria
Posted on December 28, 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.
Endothelial Keratoplasty
- Retired effective 1/1/2024
Non-Covered, Experimental and Investigational Services
- Retired effective 1/1/2024 – see Medical Necessity
Lipodystrophy Syndrome – HIV associated
- Effective 3/1/2024
- Name changed from Treatment of Lipodystrophy Syndrome (LDS)
- No significant change to criteria but codes added to align with MassHealth
Speech Therapy
- Effective 3/1/2024
- Clarified IV D 1 under policy guidelines and definitions
- Added links to Medicare and MassHealth criteria
Percutaneous Left Atrial Appendage Closure
- Effective 2/1/2024
- No changes to criteria with the exception of adding Medicare LCD
Tumor Treatment Fields
- Effective 2/1/2024
- No significant criteria changes
Hydrogen Breath Testing
- Effective 2/1/2024
- Added NCD link
- No significant changes
Dental Anesthesia
- Effective 1/1/2024
- No changes to policy, updated references for Medicare
Medical Necessity
- Update effective 1/1/2024
- Not Medically Necessary section added; this was previously on the Non-Covered Services Policy and was added with no change to criteria.
Prostate Procedures (BPH and Prostate Cancer)
- New Policy effective 3/1/2024
- The following policies will be retired and are incorporated into this policy effective 3/1/2024:
- Water Vapor Thermal Therapy
- Transurethral Water Jet Ablation
- High Intensity Focused Ultrasound (HIFU) for the treatment of Prostate Cancer
- PA added to the following CPT codes 52441, 52442, 53850, 55874
- CPT 53852 added to experimental/investigational list
Deep Brain and Cortical Stimulation
- Effective 1/1/2024
- Name changed from Deep Brain Stimulator
- Added codes that are effective 1/1/2024 for Responsive Cortical Stimulation
- Added NCD for Medicare line of business
Spinal Cord and Dorsal Root Ganglion Stimulation
- Effective 1/1/2024
- Name changed from Spinal Cord Stimulators
- No significant change to criteria
- Removed cardiac pacemakers and defibrillators from Contraindications section
- Updated Experimental/Investigational and Contraindications section
- Updated codes for 2024 CPT changes
- Added 63688 (for revision) to codes requiring PA
- Added 64553 (for trial) Code already requires PA on other policies
Achalasia and Gastroesophageal Reflux Disease (GERD) – Minimally Invasive Procedures
- Effective 2/1/2024
- Name changed from Peroral Endoscopic Myotomy (POEM)
- Criteria updated to be less restrictive
- Added procedures for GERD that are Experimental &Investigational to the policy
- Transplants
- Ventricular Assist Devices (VAD) moved to separate policy
- Updated NCDs and coding table
Transplants
- Ventricular Assist Devices (VAD) moved to separate policy
- Updated NCDs and coding table
Ventricular Assist Devices
- Effective 2/1/2024
- Was previously included in Transplant policy
- Criteria clarified, no significant change
Peripherally Implanted Nerve Stimulation (PNS)/Peripheral Subcutaneous Field Stimulation (PSFS)
- Effective 1/1/2024 (coding changes)
- Criteria clarified with no significant change
- Codes updated and added due to 2024 CPT changes
Infertility Treatment
- Effective 2/1/2024
- Moved to new template with no significant change
- Clarified biological male and biological female
- Therapeutic Contact Lens – Medical Policy
- Effective 2/1/2024
- Policy moved to new template and rewritten with no significant change to criteria
Azedra (iobenguane I-131)
- Effective 2/1/2024
- Moved to new template with no significant change
Transanal Endoscopic Microsurgery
- Effective 2/1/2024
- Moved to new template with no significant changes
- Artificial Cervical Disk
- Effective 2/1/2024
- Moved to new template with no significant changes
Abdominal Panniculectomy and Excision of Excessive Skin and Subcutaneous Tissue
- Effective 3/1/2024
- Moved to new template
- For Commercial, will use InterQual for panniculectomy
- For Medicare Advantage, will use local coverage determination (LCD) for panniculectomy
- For MassHealth, will use MassHealth guidelines for panniculectomy and removal of excessive skin
Sleep Disordered Breathing Diagnosis and Treatment
- Effective 3/1/2024
- The following policies will be retired effective 3/1/2023:
- Laser-Assisted Uvulopalatoplasty or Uvulopalatopharyngoplasty
- Upper Airway Stimulation Device (UAS)/Hypoglossal Nerve Stimulation (HGNS) (Inspire)
- Minor changes made to Diagnosis of Obstructive Sleep Apnea and Sleep Disorders
- Treatment of Obstructive Sleep Apnea (OSA) and Upper Airway Resistance Syndrome (UARS) section added
Behavioral Health Policies
Applied Behavioral Analysis for Autism Spectrum Disorder
- Effective 2/1/2024
- Moved to new template with no significant change
For more information, please do not hesitate to call your Provider Experience Department at (800) 842-4464, extension 5000, or send an email to providerrelations@hne.com.