Clinical Review Criteria – November 2020
Posted on November 4, 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.
New Medical Policies (Effective 12/1/2020)
Azedra (iobenguane I 131)
Nodify Lung Nodule Risk Assessment BDX-XL2 (Biodesix, Inc.)
New Medical Policy (Effective 1/1/2021)
Deep Brain Stimulation Treatment for Essential Tremor and Parkinson’s Disease
Reviewed and Updated (Effective 12/1/2020
Treatment of Lipodystrophy Syndrome (LDS)
• Updated Criteria for Approval – Added “Commercial, Medicare, Medicaid” to the section title
• HCPC Codes – Deleted Code C9800
• CPT Codes – Deleted Codes 15878 and 15879, as policy is for facial lipodystrophy
Surgical Management of Morbid Obesity
• Updated Criteria for Approval:
o Criteria for Approval for Ages 18 and Over
o Criteria for Approval for Adolescents Ages 13-17
o Repeat Bariatric Surgery
o Medicare
• What is Not Covered
Contact Lenses
• Updated Definitions, Scleral Shell or Shield – Added “It functions as a protective barrier against tear evaporation. Used as an artificial support and a protective covering for diseased eye or sightless or shrunken eye.”
• Updated Criteria for Approval
Cochlear Implants, BAHA (Bone Anchored Hearing Aid), and ABI (Auditory Brainstem Implant)
• Changed name of policy to add ABI
• Updated Definitions: Added description of hybrid cochlear implant
• Added HNE adopted InterQual criteria (where applicable)
• Updated headings in several sections:
From: “Adult Criteria for Approval of Cochlear Implant for Commercial/MassHealth”
To: “Criteria for Approval of Cochlear Implant for All Lines of Business”
From: “IV., Criteria for Approval of Hybrid Cochlear Implant/Hearing Aid Devices that include hearing aid integration into the external sound processor of the cochlear implant when all of the below criteria are met:”
To: “II., Criteria for Approval of Hybrid Cochlear Implant/Hearing Aid Devices (such as the Nuclear Hybrid L24 Cochlear Implant System) that include hearing aid integration into the external
sound processor of the cochlear implant when all the below criteria are met:”
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.
New Medical Policies (Effective 12/1/2020)
Azedra (iobenguane I 131)
Nodify Lung Nodule Risk Assessment BDX-XL2 (Biodesix, Inc.)
New Medical Policy (Effective 1/1/2021)
Deep Brain Stimulation Treatment for Essential Tremor and Parkinson’s Disease
Reviewed and Updated (Effective 12/1/2020
• Treatment of Lipodystrophy Syndrome (LDS)
• Updated Criteria for Approval – Added “Commercial, Medicare, Medicaid” to the section title
• HCPC Codes – Deleted Code C9800
• CPT Codes – Deleted Codes 15878 and 15879, as policy is for facial lipodystrophy
Surgical Management of Morbid Obesity
• Updated Criteria for Approval:
o Criteria for Approval for Ages 18 and Over
o Criteria for Approval for Adolescents Ages 13-17
o Repeat Bariatric Surgery
o Medicare
• What is Not Covered
Contact Lenses
• Updated Definitions, Scleral Shell or Shield – Added “It functions as a protective barrier against tear evaporation. Used as an artificial support and a protective covering for diseased eye or sightless or shrunken eye.”
• Updated Criteria for Approval
Cochlear Implants, BAHA (Bone Anchored Hearing Aid), and ABI (Auditory Brainstem Implant)
• Changed name of policy to add ABI
• Updated Definitions: Added description of hybrid cochlear implant
• Added HNE adopted InterQual criteria (where applicable)
• Updated headings in several sections:
From: “Adult Criteria for Approval of Cochlear Implant for Commercial/MassHealth”
To: “Criteria for Approval of Cochlear Implant for All Lines of Business”
From: “IV., Criteria for Approval of Hybrid Cochlear Implant/Hearing Aid Devices that include hearing aid integration into the external sound processor of the cochlear implant when all of the
below criteria are met:”
To: “II., Criteria for Approval of Hybrid Cochlear Implant/Hearing Aid Devices (such as the Nuclear Hybrid L24 Cochlear Implant System) that include hearing aid integration into the external sound
processor of the cochlear implant when all the below criteria are met:”
From: “VI., AUDITORY BRAINSTEM IMPLANT (ABI) is covered for:”
To: “IV., Auditory Brainstem Implant (ABI), unilateral, is covered for”
• Updated What is Not Covered
• Updated HCPCS and Requirements
o “Associated HCPCS that do not require PA” Changed to “Associated HCPCS”
o Removed code L8613 (not configured for PA)
o Added L8627, L8628, L8629 under cochlear devices (these codes have IQ criteria and are on config list)
o Removed code L8691 (not configured for PA)
Abdominal Panniculectomy and Removal of Excess Skin
• Changed name of policy to add “and Removal of Excess Skin”
• Updated Criteria for Approval: Commercial and Medicare
• Updated Criteria for Approval of MassHealth member – (Reviewed on a case-by-case basis)
• Updated CPT Codes: Added CPT codes in table form
Formula and Enteral Nutrition
• Staff wanted clarification of policy as it technically was only for MassHealth – now LOB has been added
• Attached to policy is a link for Northwood’s criteria, which HNE will be using for MassHealth reviews
• Added Commercial criteria info, for use with all Commercial policies
• Added Medicare link for Medicare members
Intacs Corneal Implants (Intrastromal Corneal Ring Segments
• Updated Criteria for Approval
• Updated What is Not Covered
Endothelial Keratoplasty (also known as Posterior Lamellar Keratoplasty)
• Health New England has adopted InterQual criteria
• HNE Nurse Reviewers use InterQual through Medecision’s Aerial Medical Management System
Percutaneous Left Atrial Appendage Closure
• Updated Criteria for Approval
• Updated What is Not Covered
Balloon Sinus Dilation of the Eustachian Tubes
• Code Correction – HCPC Code should be C9745 (NOT C7945)
Long-Term 30-Day Cardiac Monitoring
• CPT Codes now included – 93228 which requires PA; and 93229 which does not require PA
Therapeutic Shoe and Orthotic Coverage
• HCPCS codes added to policy
Orthognathic Surgery
• CPT codes added to policy
Rhinoplasty
• CPT codes added to policy
Reconstructive Repair of Pectus Excavatum or Pectus Carinatum
• CPT codes added to policy
