ProviderMatters

Medical Policy Updates/New Policies (July 2025)

Posted on July 2, 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 Policy – New Transcatheter Tricuspid Valve Interventions

  • New Policy effective 10/1/2025
  • Transcatheter Tricuspid Valve Replacement (TTVR) is covered for Medicare Advantage when the items and services are furnished in the context of a CMS-approved CED study and medical necessity criteria are met.
  • Experimental for Commercial and MassHealth
Medical Policy – Annual Review Transcatheter Aortic Valve Replacement (TAVR)

  • Annual Review effective 10/1/2025
  • No changes
Cosmetic and Reconstructive Procedures

  • Annual Review effective 9/1/2025
  • Added criteria for vein graft in stapedotomy
  • Updated coding table:
    • Added CPT 15769
    • Added CPT 40525-42225 (cleft plate/palate repair) – PA not required
    • Removed CPT 56805, 56835, 57335 (see Gender Affirming Services policy)
    • Removed not covered for MassHealth from CPT 56835
 

 

 Hyperbaric Oxygen (HBO) Therapy

  • Annual Review effective 10/1/2025
  • Removed “No untreated pneumothorax” from requirements for all indications
  • Removed “Nutritional evaluation performed” from requirements of Diabetic Foot Ulcer and Lower Extremity Wound
  • Added clarification to Delayed Soft Tissue Radionecrosis
  • Added to indications considered experimental investigational:
    • Chemotherapy induced hemorrhagic cystitis
    • Interstitial cystitis
  • Updated coding table: Added A4575 as experimental/investigational
Proton Beam Therapy

  • Annual Review effective 10/1/2025
  • No changes
Reconstructive Repair of Pectus Deformity

  • Annual Review effective 9/1/2025
  • No criteria changes
Sacroiliac Joint Fusion for the Treatment of Adult Low-Back Pain

  • Annual Review effective 9/1/2025
  • Added revision of SI joint stabilization to Experimental/Investigational section
Intradialytic Parenteral Nutrition

  • Annual Review effective 9/1/2025
  • No criteria changes
  • Removed prior authorization requirement
  • References updated
Rhinoplasty and Other Nasal Surgeries

  • Annual Review effective 10/1/2025
  • Added criteria for Reconstructive Rhinoplasty
  • Added criteria for Revision Rhinoplasty
  • Added criteria for Tip Rhinoplasty
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Categories: Provider Newsletter

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