ProviderMatters

Medical Policy Updates (September 2025)

Posted on September 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.

 

Medical Policy –  Annual Review Effective Date  Summary of Changes 
Home Health Care Services Medicaid  11/1/2025 
  • Updated Physical and Occupational Therapy criteria to follow the outpatient therapy guidelines. (This aligns with the MassHealth Guidelines for Home Health.)
  • In “Limitations and Exclusions,” removed paragraph regarding Maintenance Home Health Care Services as this is addressed in the Home Health Aid (HHA) only criteria.
Clinical Trial 10/1/2025 
  • In “What is Not Covered,” clarified number 8, costs of services.
  • Updated Definitions (HUD and HDE) and References.
Artificial Cervical Intervertebral Disc   10/1/2025 
  • Added InterQual criteria for Cervical Artificial Disc Removal and Replacement. PA not required for the procedures.
  • Added CPT codes 22861 and 22864 to the coding table.
  • PA not required.
Bone Grafts and Stabilization Devices for Spinal Defects 10/1/2025 
  • Minor Criteria Changes
  • Experimental and Investigational bone graft substitutes list reviewed and updated.
  • Experimental and Investigational Interlaminar Stabilization Devices list reviewed and updated.
Medical Necessity and Experimental and Investigational 10/1/2025 
  • Experimental and Investigational definition revised.
  • Under “Policy Guidelines,” added InterQual “CP: Procedures” Criteria as IA2.
Abdominal Panniculectomy and Excision of Excessive Skin and Subcutaneous Tissue 10/1/2025 
  • Minimal changes to criteria
Azedra
  • No changes to criteria

 

Medical Policy –  New Effective Date  Summary of Changes 
Hospice and Palliative Care  11/1/2025 
  • Services have required PA, but did not have medical necessity criteria in the past.
  • Applies to Commercial and MassHealth lines of business (Medicare Advantage is covered by Medicare fee-for-service and not Health New England).
Long-Term Acute Care (LTAC) 10/1/2025 
  • Documents current process.
  • Applies to all lines of business.

 

Medical Policy –  Quarterly Effective Date  Summary of Changes 
Skin and Soft Tissue Substitutes  7/1/2025 
  • Q4368, Q4369, Q4370, Q4371, Q4372, Q4373, Q4375, Q4376, Q4377, Q4378, Q4379, Q4380, Q4382 added to Experimental/Investigational list, effective 7/1/2025.
  • Q4132, Q4137, Q4154, Q4168 removed from the Experimental/Investigational list.
  • Added ophthalmic conditions to covered conditions.

 

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