ProviderMatters

Clinical Review Criteria (June 2024)

Posted on June 4, 2024

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.

  • Nutritional counseling
    • No changes.

 

  • Lymphedema- Surgical Treatment
    • No changes.

 

  • Blepharoplasty and Browplasty
    • No changes.

 

  • Cosmetic and Reconstructive Procedures
    • Criteria in section E4 clarified; no other change to criteria.

 

  • Bariatric Surgery
    • MassHealth adults will use MassHealth criteria instead of Health New England criteria, effective 7/1/2024.
    • Other criteria clarified with no significant change.

 

  • Infertility Treatment
    • Effective May 1, residency requirements have been removed from the policy.

 

  • Sacroiliac Joint Fusion  for the Treatment of Adult Low-Back Pain
    • Effective 7/1/2024.
    • Minor changes, definitions added.

 

  • Photochemotherapy (PUVA) – Phototherapy – Laser Treatments – Photodynamic Therapy  (PDT)
    • Effective 7/1/2024.
    • No significant changes.

 

  • Preimplantation Genetic Testing
    • Effective 7/1/2024.
    • No significant changes.

 

  • Percutaneous Neuroablation
    • Effective 8/1/2024.
    • Replaces Radiofrequency Ablation policy with updated criteria.
    • Removed Thermal destruction of intraosseous basivertebral nerve (CPT codes 64628 and 64629) from the experimental list and covered when criteria is met.

 

  • Breast Surgery
    • Effective 8/1/2024.
    • InterQual criteria replaced internal criteria for Reconstructive Breast Surgery, Surgical Management of Breast Implants, Female Breast Reduction, and Surgical Treatment of Gynecomastia.
    • LCD L35001 added for Reduction Mammoplasty.

 

If you have any questions about the information in this notice, please contact Health New England Provider Experience at (800) 842-4464, extension 5000. A representative is available Monday through Friday between the hours of 8:00 a.m. and 5:00 p.m. You may also send an email to providerrelations@hne.com.

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