Clinical Review Criteria – June 2020
Posted on June 2, 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.
MEDICAL POLICIES:
Updated Policies Effective 8/1/2020:
- Biofeedback for Urinary Diagnoses
- Orthognathic Surgery
- Rhinoplasty
- Adopted InterQual criteria
- InterQual criteria is available upon request
- Bone Grafts for Spinal Defects
- Under Definitions: Deleted isthmic spondylolisthesis and isthmus
- Updated Criteria for approval
- Updated Required Documentation
- What is Not Covered:
- A.: Added items 6. through 16.
- B.: Deleted entire statement (HNE considers Coflex as Experimental/Investigational for the following: Commercial and Medicaid lines of business)
- Coflex
- Changed From: Coflex is covered for Medicare line of business **ONLY.**
- Changed To: Coflex is NOT covered for any line of business.
- Deleted reference to Medicare site
- Clinical Trial for Medicare Advantage Members
- Updated Criteria for Approval
- Updated What is Not Covered
- Clinical Trials
- Added additional disclaimer
- Updated phases of clinical trials
New Policies effective 8/1/2020
- Reconstructive Repair of Pectus Excavatum or Pectus Carinatum
- Balloon Sinus Dilation of the Eustachian Tubes
Archived Policies
- Fecal Microbiota Transplant
BEHAVIORAL HEALTH POLICIES:
No changes to the following policies:
- Access to Behavioral Health
- Day Treatment Services
- Concurrent Review for Inpatient Rehab for Substance Use Disorder
- Autism Spectrum Disorders
- Continuity and Coordination Between Medical Care and Behavioral Healthcare
The following change was made:
- Neuropsychological Testing
- Changed the name to identify that this policy is only for Medicare Advantage. Removed any reference to “psychological testing” as this policy is for NeuroPsych testing.
*Please note new/revised policies may not appear until closer to the effective date.
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