ProviderMatters

Medical Policy Update (Dec. 2024)

Posted on December 9, 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.

Policy Review Notes
Update Breast Surgery

  • Policy updated to add Z85.3 to the list of ICD-10 codes for Breast Cancer; effective 11/1/2024.
Medical Policies PANS/PANDAS

  • Annual Review with no changes; effective 2/1/2025.

 

Chimeric Antigen Receptor Therapy

  • Updated due to CPT code changes; effective 1/1/2025.
  • Removed CPT codes 0537T-0540T and added CPT codes 38225-38228 PA required.
  • No change to criteria

 

Prostate Procedures (BPH and Prostate Cancer)

  • Updated due to CPT code changes; effective 1/1/2025.
  • CPT codes 51721, 55881, 55882, 53865, 53866 added to policy as experimental/investigational.
  • No change to criteria.
Updates Transanal Endoscopic Microsurgery (medical policy) will be retired, effective 1/1/2025, due to low utilization.
Behavioral Health Policies Recovery Coaching

  • New policy; effective 1/1/2025.
  • Commercial line of business only.

 

Recovery Support Navigator (RSN)

  • New policy; effective 1/1/2025.
  • Commercial line of business only.
Benefit Reminder Health New England Medicare Advantage plans

  • Annual Wellness Visit: Covered once per calendar year.
Policy Review Notes
  • Provides greater flexibility and convenience for both providers and members.

 

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