ProviderMatters

Medical Policies Updates (June 2025)

Posted on June 4, 2025

Please read the following update related to various Health New England programs and changes that may have an impact on your patients and/or your practice.

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.

 

Updates Notes
Medical Policies Nutritional Counseling for Eating Disorders

  • Effective 07/01/2025
  • Annual review
  • Added ICD-10 codes F50.83 and F50.84 to list of medically necessary diagnosis codes
  • No changes to criteria
Blepharoplasty and Browplasty

  • Effective 07/01/2025
  • Annual review
  • Description updated
  • MassHealth guidelines added for Medicaid line of business
  • Otherwise, minor criteria changes
Breast Surgery

  • Effective 08/01/2025
  • Annual review
  • Transitioned to InterQual criteria for Risk-Reducing (Prophylactic) Mastectomy
  • CPT 19318 – Breast Reduction/Reduction Mammaplasty removed from list of codes that do not require PA with diagnosis of breast cancer. Procedure will require PA regardless of diagnosis.
  • References updated
 

 

 Chimeric Antigen Receptor T-Cell Therapy

  • Effective 04/01/2025
  • Annual review and update
  • Updated MassHealth process for approval through the MassHealth Drug Utilization Review (DUR) Program
  • Added C9301 to coding table
  • Minor title revision
  • No additional changes
Peripherally Implanted Nerve Stimulation (PNS), Peripheral Subcutaneous Field Stimulation (PSFS)

  • Effective 07/01/2025
  • Annual review
  • Percutaneous electrical nerve field stimulator (PENFS) system criteria added
  • No significant criteria changes to peripheral nerve stimulation (PNS) or peripheral nerve field stimulation (PNFS)
  • Coding table updated added 0702T and updated 64999 to include PENFS for MassHealth
  • References updated
Gender Affirming Services

  • Effective 07/01/2025
  • Annual review
  • For members over 18, removed requirement that the surgeon must consult with the member’s PCP and behavioral health provider.
  • Added requirement for hormone replacement therapy (WPATH recommendation)
  • 6 months of hormone therapy required before gender affirming services
  • Increased Cryopreservation of Eggs or Sperm from one year to five years
Percutaneous Neuroablation

  • Effective 07/01/2025
  • Annual review
  • CPT 64625, radiofrequency ablation to the SI joint, was updated to covered with prior authorization
  • Adalimumab biosimilar
Photochemotherapy (PUVA) – Phototherapy – Laser Treatments – Photodynamic Therapy (PDT)

  • Effective 07/01/2025
  • Annual review
  • Removed prior authorization requirement after 35 visits
Ambulatory Electrocardiograph Monitoring

  • Effective 07/01/2025
  • Annual review
  • Minor changes to criteria
Preimplantation Genetic Testing

  • Effective 07/01/2025
  • Annual review
  • Criteria added for PGT-A (previously experimental/investigational for all indications)
Skin and Soft Tissue Substitutes

  • Effective 06/01/2025
  • Updated with coding and LCD changes
  • Added new codes effective 4/1/2025 (all experimental/investigational)
  • Removed reference to LCD L39828 and LCA A59712 due to CMS delay of implementation
Bone Mineral Density Measurement  

  • Effective 08/01/2025
  • New Policy
  • Codes added to not medically necessary: 78350 and 78351 for all lines of business, 76977 for Commercial and MassHealth only
  • Codes added to experimental and investigational: 77089 and 77090
  • Authorization not required
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