ProviderMatters

Medical Policy Updates (October 2025)

Posted on October 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.

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.

Medical Policy Updates   Effective Date  Notes 
Lipodystrophy Syndrome – HIV Associated  10/1/2025 
  • Annual review.  
  • No changes.  
Breast Surgery 

 

  10/1/2025 

 
  • Updated with the following changes: 
    • Removed Reconstructive Breast Surgery Interqual criteria from the Medicare line of business section. 
    • Added C50.A0-C50.A2, Z42.1 to the list of diagnosis codes for breast cancer.  
Cochlear Implants, BAHA (Bone-Anchored Hearing Aid), ABI (Auditory Brainstem Implant), ABI (Auditory Brainstem Implant), Bone-Conduction Hearing Aid   10/1/2025 
  • Annual review. 
  • Bone-Conduction Hearing Aid Semi-implantable and fully implantable middle ear hearing devices are added to the EXPERIMENTAL and INVESTIGATIONAL list. 
Home Health Care Services (Commercial and Medicare)  10/1/2025 
  • Annual review.  
  • No changes to criteria.  
Achalasia and Gastroesophageal Reflux Disease (GERD) – Minimally Invasive Procedures 

 

 10/1/2025 
  • Annual review. 
  • Minor changes POEM and GPOEM changed not medically necessary vs. experimental/investigational when medical necessity criteria is not met.  
Non-Emergent Transportation 

 

  10/1/2025 
  • Annual review.  
  • No changes to criteria.  
Leadless Cardiac Pacemaker 

 

  10/1/2025 
  • New Policy.  
  • Certain leadless cardiac pacemakers moved from experimental/investigational to covered for the commercial and Medicare lines of business. (Have been covered by Medicare under a National Coverage Determination, NCD). 
  • No prior authorization required. 
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