November 2021 Clinical Review Criteria
Posted on October 29, 2021
Each month, Health New England reviews clinical criteria and policies with our Clinical Care Advisory Committee and Medical Technology Assessment Committee. When changes occur, we update policies, if applicable, and inform our network accordingly. Below are recent updates you need to know when caring for our members:
For Fully Funded Commercial and Medicaid, the following are considered experimental/investigational and will not be covered. As mandated, we will cover for Medicare Advantage:
- Absorbable Nasal Implant for the Treatment of Nasal Valve Collapse (i.e. Latera)
- Cryoablation for the treatment of chronic rhinitis (i.e. Clarifix)
Effective February 1, 2022, For Fully Funded Commercial, the following services and procedures require Prior Approval:
- These CAR-T treatments are covered with Prior Approval:
- Tecartus for the treatment of relapsed or refractory Mantle Cell Lymphoma
- ABECMA for the treatment of relapsed or refractory Multiple Myeloma
To learn more, policies reside at healthnewengland.org/Providers/Resources. Once on the Resources page, click on Behavioral Health/Medical Policies or Payment Policies.
*Please note, new/revised policies may not appear until closer to the effective date.
