Medical Policy Title

Policy Number

Description of Change

Effective Date

LOB Affected

Policy Type

Added additional information to Corneal contact lens and Scleral contact lens, and added 4 new definitions

·  I., General Criteria for Approval

o   Added Medicare and Commercial to the heading

o   B., 2.:  Removed “MassHealth and” from statement

·  III., What is Not Covered:  Medicare and Commercial

o   New (formerly V.)

o   Updated numbering on sections that follow

·   IV., Medically Necessary for MassHealth Members

o   Formerly III.

o   Letter F. added and 4 statements below it

o   Added “For additional information:” and the Mass.gov link

·  VI., What is Not Covered under MassHealth

o   Added VI., including 7 items

·  VII., Eyeglasses

o   Added VII., including 3 items

·  Added table of HCPCS

·  Added table of CPT Codes, including statement “NO PA **Covered only when member meets criteria for contact lenses**”

·  Source/Citation Section

o   Sources and citations retrieved and updated

o   Added Medicare Coverage Database citation

o   Eliminated Yoo, D citation

o   Added 2 citations re:  Absorptive lenses

Medicare

Medicaid

·  Source/Citation Section:  Confirmed citations and added 2 new citations

Medicare

Medicaid

(iobenguane I 131)

·  I., Criteria for Approval of Azedra

A., 5. was added:  “Member has had an administration of inorganic iodine.”

· III., What is Not Covered

o   D. was added:  “Members on concomitant drugs that reduce catecholamine uptake or deplete catecholamine stores”

o   E. was added:  “Severe renal impairment (creatinine clearance <30)”

·  Source/Citation Section:  Sources were confirmed and updated.

Medicare

Medicaid

Added Unilateral Hearing Loss (UHL), Single-Sided Deafness (SSD), Soundbites; and related definitions

· I., Criteria for Approval

Changed statement

From:  Criteria for Approval of Cochlear Implant – for All Lines of Business:

To:       Criteria for Approval of Initial Cochlear Implant Only (including unilateral hearing loss).  See below for information regarding replacement – for All Lines of Business:

·  II., E.

Added the underlined:

E., Member displays ANY of the below hearing thresholds:

· V., What is Not Covered

o   Deleted B.:

B., Cochlear implantation, including hybrid implants, as a treatment for patients with unilateral hearing loss with or without tinnitus is investigational.

o   H. was added

o   I. was added

·  Source/Citation Section:

All citations confirmed

·  Additional Resources:

All confirmed

Medicare

Medicaid

·  Source/Citation Section:  All confirmed with 1 new one added

Medicare

Medicaid

A.:  Added the underlined:

“No prior authorization is required for HBT.  Policy is in place to support claim-confirmed 5/13/2021 by JS.”

·  Source/Citation Section:  All citations confirmed

Medicare

Medicaid

·  Source/Citation Section:  All sources and citations were retrieved and confirmed; one new source added.

Medicare

Medicaid

o   Added C.:  “The member is 18 years of age or older on the date of services AND”

o   With the addition of C., the remaining lettering in this section was updated.

o   E. (formerly D.):  Corrected the spelling of the words redundant and subcutaneous

·  III., Required Documentation

Formerly V. including A. thru F.  Moved up from further in the document, renamed III.

·   IV., Criteria for Approval of MassHealth member.  Follow link below.  (Reviewed on a case-by-case basis)

o   Formerly III., changed to new IV., MassHealth link added

o   Deleted residual information under MassHealth criteria:  A-J

·  Former IV. eliminated

·  CPT Codes:  Confirmed all codes on Y/N list

·  Source/Citation Section

o   Confirmed all citations

o   Added:  “MassHealth Guidelines for Medical Necessity Determination for Excision of Excessive Skin and  Subcutaneous Tissue, Retrieved April 27, 2021, from: https://www.mass.gov/guides/masshealth-guidelines-for-medical-necessity-determination-for-excision-of-excessive-skin-and

o   Confirmed above link ends with “and”

Medicare

Medicaid

A.

o   Added the underlined to the 3^rd bullet:

·   “documented enrollment in a program that provides multidisciplinary evaluation and includes behavioral health, nutrition and medical management pre-op within 6 months prior to surgery and post-op”

o   Added the underlined after 7^th bullet after OR:

·    “evidence of fatty liver disease (non-alcoholic fatty liver disease (NAFLD)”

B.   Original statement #1. was deleted, with the following statement added in its place:

1.   “Documentation from the treating surgeon attesting that the member meets criteria and believes the member is likely to benefit from surgery.  AND”

·  II., Criteria for Approval for Adolescents
B.

o   Bullet 2:  Added “Apnea Hypopnea Index”

o   Bullet 3:  Added “(Non-alcoholic Steatohepatitis)”

·  III., Repeat Bariatric Surgery

E.   Added E., “Major surgical complications including anastomotic leak or stricture, band erosion, fistula, stomal stenosis, staple line dehiscence, band slippage, bowel obstruction, GI bleeding, GERD refractory to maximum medical treatment”

·   IV., Medicare:

o   Added “LCD is followed for review.” to the heading

o   Added Medicare link

o   Removed statements A., B. and C., and corresponding sub-statements

·  V., Required Documentation

From:  Clinical notes referring to all of the above

 To:  Clinical notes documenting all of the above

 ·   VI., What is Not Covered

F., Added the following 8 bullets

·   Vertical Banded Gastroplasty (VBG)

·   Biliopancreatic diversion (BPD)  (BMC)

·  Laparoscopic gastric plication or laparoscopic greater curvature plication

·  Roux-en-Y gastric bypass (short limb or long limb) combined with simultaneous gastric banding

·  When used for GERD

·  Duodenal switch with single anastomosis

·  Parietal cell separating gastrojejunostomy

·  Two-stage bariatric surgery procedures

·  CPT Codes:  Added “NO PA” to the following codes:

·  Source/Citation Section:  All citations confirmed, with 3 added

Medicare

Medicaid

B.:  Corrected the Medicare link

·  Source/Citation Section:

Citations confirmed and corrected if needed (#5)

·  Source/Citation Section:  Confirmed with 1 new citation added

Medicare

Medicaid

Added “All Lines of Business”

·  CPT Codes:

o   Added “(Confirmed all on Y/N List)”

o   Deleted “+” in front of code 61864

·  Source/Citation Section:

Added 3 citations

Medicare

Medicaid

o   Added “Commercial and MassHealth (Confirmed with Commonwealth Care Alliance)”

o   A., 2.:  added “Temozolomide”

·  II., (New)

o   Added II., Criteria for Approval for Medicare – Follow link below:

https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=34823

o   Former II. changed to III

o   Former III. changed to IV.

· IV., What is Not Covered

Added letters I., J., and K.

· V., HCPC Code (Former IV.)

Code A4555 is removed.

·  Source/Citation Section:

Confirmed, with 4 new citations added

Medicare