January 2020 – Clinical Review Criteria

Posted on February 10, 2020

Health New England’s Clinicial Policies have been updated and can be found at healthnewengland.org/providers/resources. On the Resources page, click on “Behavioral Health/Medical Policies” section to learn of the changes.

Effective 4/1/2020

Hyperbaric Oxygen Therapy (Outpatient Services)

• Added 14 new definitions
• Made adjustments to the “Criteria for Approval”
  • Removed B: “Requests for HBO Therapy for the treatment of cutaneous, decubitus, and stasis ulcers as listed under “What is Not Covered,” III, A, 1, are forwarded for Medical Director review for consideration for coverage as a benefit exception. Consideration is given when HBO Therapy is requested by or in consultation with a vascular surgeon.”
• Made adjustment under “What is Not Covered”
• Added Wagner Grading System & definition of each grade noted (Grade 0 to Grade 5)
• Removed CPT Code 99183

Reconstructive Breast Surgery Following Mastectomy or Breast Conserving Surgery

• Added 8 new definitions
• Adjusted “Coverage Limitations and Exclusions
  • A., 1. Added the underlined: “If the breast reconstruction has been successfully completed postmastectomy/breast conserving surgery with implants and the enrollee chooses to enlarge or decrease in size their breast after a period of time, this is considered a cosmetic service and not a covered benefit in accordance with member’s plan coverage.”
  • Eliminated B. “Scar revision is a covered service postmastectomy/breast conserving surgery including donor site following flap reconstruction.”
  • Removed D. “Autologous fat grafting during the reconstruction phase postmastectomy/breast conserving surgery is a covered benefit.”
  • Added J. “Breast reconstructive surgery to correct breast asymmetry is considered cosmetic EXCEPT…” and items 1-4.

Gender Reassignment Surgery
Added the following procedure codes:

• 19325 Mammoplasty, augmentation with prosthetic implant
• 19328 Removal of intact Mammary implant
• 19330 Removal of intact Mammary implant material
• 19370 Open Periprosthetic capsulectomy
• 19371 Periprosthetic capsulectomy
• 19396 Preparation of Moulage for custom breast implant

Infertility Treatment

Recommended entire policy be reviewed due to significant changes.

Surgical Treatment of Gynecomastia

• Added 2 new definitions
• Significant changes with “Criteria for Approval” for all product lines
• Added a new item under “What is Not Covered”
  •  9. (new) Added: Gynecomastia surgery using liposuction as the sole surgical procedure
• Removed ICD-10 Diagnosis section

Archived January 2020
Wearable Cardiac Defibrillator (e.g., LifeVest)

*Please note new/revised policies may not appear until closer to the effective date.

Categories: Provider Newsletter