July 2020 – Clinical Review Criteria
Posted on July 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 9/1/2020
Knee Braces
• Definition changes with Prefabricated Braces
Changed From:
Prefabricated Braces: (L1810-L1833, L1836, L1843, L1845, L1847, L1850 and L1852) Generally attempted prior to using a custom fitted orthosis. These braces are off-the-shelf and may be purchased in stores.
Changed To:
Prefabricated Braces: (L1810, L1812, L1820, L1830 – L1833, L1836, L1843, L1845, L1847, L1848, L1850, L1851, L1852) Generally attempted prior to using a custom fitted orthosis. These braces are off-the-shelf and may be purchased in stores. These braces come in a selection of sizes (small, medium, large, extra-large) and only require measurements and a sizing chart for fitting. Minimal adjustments will be made.
• Updated Criteria for Approval
• Updated What is Not Covered
Speech Therapy
• Updated Criteria for Approval
• Required Documentation for Initial Determination
• Update What is Not Covered
Total Ankle Replacement
• Health New England has adopted InterQual criteria. Health New England Nurse reviewers use InterQual through Medecision’s Aerial medical management system.
• InterQual criteria are available upon request by members and providers.
Proton Beam Therapy
• Health New England has adopted InterQual criteria. Health New England Nurse reviewers use InterQual through Medecision’s Aerial medical management system.
• InterQual criteria are available upon request by members and providers.
Laser-Assisted Uvulopalatoplasty or Uvulopalatopharyngoplasty
• Health New England has adopted InterQual criteria. Health New England Nurse reviewers use InterQual through Medecision’s Aerial medical management system.
• InterQual criteria are available upon request by members and providers.
• Updated Criteria for Approval.
Upper Airway Stimulation Device (UAS)/Hypoglossal Nerve Stimulation (HGNS) (Inspire)
• Updated Criteria for Medicare Approval
From:
(Medicare is reimbursing the cost of Inspire therapy based on medical necessity in many geographies across the United States. An Inspire trained physician can discuss Medicare coverage in your area during an initial consultation.) There is no NCD.
To:
As of 4/1/2020, Medicare covers hypoglossal nerve stimulation for treatment of sleep apnea. LCD is L38387. Criteria for medical necessity is located at the CMS link here.
Transplants and Ventricular Assist Devices
• Added Medicare approval information with Ventricular Assist Devices (VAD) and facilities
• Updated What is Not Covered
Reconstructive Breast Surgery Following Mastectomy or Breast Conserving Surgery
• Additional CPT Codes:
15769
Grafting of autologous soft tissue, other, harvested by direct excision (e.g., fat, dermis, fascia)
15771
Grafting of autologous fat harvested by liposuction technique to trunk, breasts, scalp, arms, and/or legs; 50 cc or less injectate
15772
Grafting of autologous fat harvested by liposuction technique to trunk, breasts, scalp, arms, and/or legs; each additional 50 cc injectate, or part thereof (List separately in addition to code for primary procedure.)
15773
Grafting of autologous fat harvested by liposuction technique to face, eyelids, mouth, neck, ears, orbits, genitalia, hands and/or feet; 25 cc or less injectate
15774
Grafting of autologous fat harvested by liposuction technique to face, eyelids, mouth, neck, ears, orbits, genitalia, hands and/or feet; 25 cc or less injectate: each additional 25 cc injectate, or part thereof
Archived Policies
• Total Hip Resurfacing
*Please note new/revised policies may not appear until closer to the effective date.
