Clinical Review Criteria: May 2024

Posted on April 26, 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.

• Skin and Soft Tissue Substitutes: Updated MassHealth coverage due to new Guidelines for Medical Necessity Determination for Skin Substitutes. Q4159 Affinity, and Q4196, PuraPly now covered for this line of business only.

• Infertility Treatment: Intra-Cytoplasmic Sperm Injection (ICSI) criteria clarified.

• Prostate Procedures (BPH and Prostate Cancer):Updated criteria for high-energy water vapor thermotherapy for the Medicare line of business due to NGS retiring LCD L37808.

• Behavioral Health Day Treatment: Reviewed with no changes.
• Family Stabilization Team: Reviewed with no changes.
• Inpatient Rehabilitation (ASAM Level 3.7) for Substance Abuse: Reviewed with no changes.
• Neuropsychological Testing, Psychological Testing, and Neurobehavioral Status Exam: Medicare Advantage will use InterQual criteria vs LCD. Clarified Neurobehavioral Testing and psychological testing – no change to criteria.
• Transcranial Magnetic Stimulation (TMS): Reviewed with no changes.

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.

Categories: Provider Newsletter