ProviderMatters

Medical Policy Update (Jan. 2025)

Posted on January 6, 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.

 

Policy Review Notes
Updates Peripherally Implanted Nerve Stimulation (PNS), Peripheral Subcutaneous Field Stimulation (PSFS) policy to be retired effective 3/1/2025.

  • CPT codes 64555, 64596, and 64598 will be experimental and investigational, effective 3/1/2025.
  • This is due to review of literature and industry standards around coverage of these procedures.
Medical Policies Chimeric Antigen Receptor Therapy

  • Updated policy effective 1/1/2025.
  • Removed 0537T-0540T and added 38225-38228 due to CPT 2025 coding updates.
  • Changed name of Magellan to Prime Therapeutics.
Lutetium Therapeutic Radiopharmaceuticals

  • Annual review effective 2/1/2025.
  • No changes to criteria.
Transplants

  • Annual review effective 2/1/2025.
  • No changes to criteria.
Ventricular Assist Devices

  • Annual review effective 3/1/2025.
  • Added Temporary Total Artificial Heart (TAH-t) to Description section.
  • Policy Section
    • Section I: Added medical necessity criteria for ventricular assist device.
    • Section III: Added criteria for pediatric ventricular assist device.
    • Section V: Added criteria for total artificial heart.
  • Removed total artificial heart and percutaneous VAD from what is not covered.
  • Policy Guidelines and Definitions
    • Added percutaneous ventricular assist devices (pVAD).
  • Coding Guidance
    • Added codes for total artificial heart.
Outpatient Physical and Occupational Therapy

  • Annual Review effective 3/1/2025
  • Title changed to Outpatient Physical and Occupational Therapy.
  • Section II: Not Medically Necessary Services for Commercial Line of Business
    • Clarified criteria in line E
    • Added line L- Any service(s), program(s), supply, or procedure performed in a non-conventional setting, which includes, but is not limited to, spas/resorts; educational, vocational, or recreational settings; Outward Bound or wilderness, camp or ranch programs. This is the case even if the services are performed by a licensed provider including, but not limited to, mental health professionals, nutritionists, nurses or physicians.
    • Clarified criteria in line N.
    • Added line O- Life coaching.
  • Added Section VIII- PT and OT services rendered in a Skilled Nursing Facility are only approved for 30 days at a time for all lines of business.
  • Required Documentation section updated
    • A.1. updated prescription for therapy was written within last 30 days.
    • B.1. clarified that both long and short-term goals are addressed.

 
Infertility Treatment

  • Annual Review effective 2/1/2025.
  • No changes.
Skin and Soft Tissue Substitutes

  • Annual review with updates.
  • Added LCD 39828 and LCA A59712, effective 2/12/2025 to policy.
  • Codes added to Diabetic Foot Ulcer as covered: A2019, Q4110, Q4121, Q4158, Q4159, Q4160, Q4187, Q4203.
  • Codes removed from Diabetic Foot Ulcer as covered: Q4101, Q4102, Q4104, Q4106 Q4114, Q4132, Q4168, Q4186, Q4196.
  • Updated applicable diagnosis codes to Diabetic Foot Ulcer section.
  • Lower Extremity Skin Ulcer section renamed Diabetic Foot Ulcer (DFU) or Venous Leg Ulcers (VLU).
  • Added Q4151 to Diabetic Foot Ulcer (DFU) or Venous Leg Ulcers (VLU) as covered.
  • Removed Q4104, Q4100, Q4124 from Diabetic Foot Ulcer (DFU) or Venous Leg Ulcers (VLU).
  • Updated applicable diagnosis codes to Diabetic Foot Ulcer (DFU) or Venous Leg Ulcers (VLU).
  • Codes added to Experimental Investigational list: Q4114, Q4132, Q4168, Q4311-Q4353.
  • Codes removed from Experimental and Investigational list: A2019, Q4121, Q4158, Q4159, Q4160, Q4187, Q4203.
  • References updated.
Tumor Treatment Fields

  • Annual review effective 2/1/2025.
  • No criteria changes.
Gender Affirming Services

  • Annual review effective 2/1/2025.
  • No criteria changes.
Hyperbaric Oxygen (HBO) Therapy

  • Annual review effective 3/1/2025.
  • Commercial and MassHealth criteria revised.
Behavioral Health Policies Applied Behavioral Analysis for Autism Spectrum Disorder

  • Annual review effective 2/1/2025.
  • No changes to criteria.
Drug Testing in Substance Use Disorder Treatment and Pain Management

  • Annual review effective 3/1/2025.
  • Added to what is not covered section: Definitive Drug Testing Services in case of positive Presumptive Drug Testing that is not supported by informed clinical rationale (decision-making) is considered not medically necessary.
Medicare Advantage and Qualified Medicare Beneficiary (QMB) Program

 

 Reminder

  • The Qualified Medicare Beneficiary (QMB) Program is one of the four Medicare Savings Programs that allows Enrollees to get help from the state to pay Medicare premiums and cost sharing. Some Health New England Medicare Advantage members have this benefit, and the Federal law prohibits Medicare providers from collecting coinsurance, copayments and deductibles from those enrolled in this program.
Prescription Drug Coverage Commercial

  • Tier 1- Lowest copay level
  • Tier 2- Mid copay level
  • Tier3- Highest copay level

 

Step Therapy Drug changes effective January 1, 2025:

For Health New England to cover the step therapy drugs listed here, you first must try the corresponding first line drugs. If Health New England has paid a claim for the first line drug within the previous 365 days, then you are eligible for coverage of the step therapy drug.

The use of samples does not satisfy the requirements of documented usage of a first line drug or medical necessity for a step therapy drug.

If it is medically necessary for you to use a step therapy drug before trying a first line drug, then your provider can contact Health New England to request a medical review.

All new Step Therapy requirements apply only to new prescriptions.
You must try: First Line Drugs:
  • Naproxen immediate release
Before HNE will cover: Step Therapy Drug(s):
  • Naproxen delayed release 375mg and 500mg
Quantity Limit Additions

Starting January 1, 2025, Health New England will add Quantity Limits to the drugs below.
Drug Name Quantity Limit per 30-day supply (unless otherwise specified)
  • First-Omeprazole
 300 mL
  • Mycophenolate solution
 160 mL
  • Guanfacine extended release
 60 tablets
Effective January 1, 2025, the following Medication Require Prior Authorization through Magellan/Prime Therapeutics.
  • Supprelin LA
Effective January 1, 2025, the following Medication is Not Covered.

See below for Covered Formulary Alternatives.
  • Humira – formulary alternative: adalimumab biosimilar
Effective January 1, 2025, the following Medications Will Have Age Restriction of 13 years old or less.
  • Naproxen suspension 125mg/5mL
  • First-Omeprazole
  • Mycophenolate solution
Effective January 1, 2025, the following Medications Will No Longer Require Step Therapy.
  • Telmisartan
  • Ciclopirox 8% solution
  • Adapalene-Benzoyl Peroxide gel 0.1-2.5%
  • Adapalene-Benzoyl Peroxide gel 0.3-5.2%
Effective January 1, 2025, the following Medication Will No Longer Skip Deductible for High Deductible Health Plans.
  • Paxlovid
Effective January 1, 2025, the following Medications Require Prior Authorization through OptumRx.
  • Aveed
  • Envarsus XR
  • Edex
  • Caverject
  • Astagraf XL
Effective January 1, 2025, the following Medication Will be Covered for Treatment for Preeclampsia with a Maximum Age of 55.
  • Aspirin 81 mg
Effective January 1, 2025, the following Medication Will be Covered for Members 45-75 years old with no copayment.
  • Bowel Prep Agents
Effective January 1, 2025, the following Medications Are Limited to a 30-day supply.
  • Ozempic
  • Trulicity
  • Victoza
  • Byetta
  • Bydureon
  • Mounjaro

 

 

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