{"id":5044,"date":"2020-02-10T15:55:52","date_gmt":"2020-02-10T15:55:52","guid":{"rendered":"http:\/\/hnetalk.com\/provider\/?p=5044"},"modified":"2020-02-10T16:02:02","modified_gmt":"2020-02-10T16:02:02","slug":"january-2020-clinical-review-criteria","status":"publish","type":"post","link":"http:\/\/hnetalk.com\/provider\/january-2020-clinical-review-criteria\/","title":{"rendered":"January 2020 &#8211; Clinical Review Criteria"},"content":{"rendered":"<p>Health New England\u2019s Clinicial Policies have been updated and can be found at <a href=\"http:\/\/healthnewengland.org\/providers\/resources\" target=\"_blank\" rel=\"noopener\">healthnewengland.org\/providers\/resources<\/a>. On the Resources page, click on &#8220;Behavioral Health\/Medical Policies&#8221; section to learn of the changes.<\/p>\n<p><strong>Effective 4\/1\/2020<br \/>\n<\/strong><br \/>\n<strong>Hyperbaric Oxygen Therapy (Outpatient Services)<\/strong><\/p>\n<ul>\n<li>Added 14 new definitions<\/li>\n<li>Made adjustments to the \u201cCriteria for Approval\u201d\n<ul>\n<li>Removed B: \u201cRequests for HBO Therapy for the treatment of cutaneous, decubitus, and stasis ulcers as listed under \u201cWhat is Not Covered,\u201d III, A, 1, are forwarded for Medical Director review for consideration for coverage as a benefit exception. Consideration is given when HBO Therapy is requested by or in consultation with a vascular surgeon.\u201d<\/li>\n<\/ul>\n<\/li>\n<li>Made adjustment under \u201cWhat is Not Covered\u201d<\/li>\n<li>Added Wagner Grading System &amp; definition of each grade noted (Grade 0 to Grade 5)<\/li>\n<li>Removed CPT Code 99183<\/li>\n<\/ul>\n<p><strong><br \/>\nReconstructive Breast Surgery Following Mastectomy or Breast Conserving Surgery<\/strong><\/p>\n<ul>\n<li>Added 8 new definitions<\/li>\n<li>Adjusted \u201cCoverage Limitations and Exclusions\n<ul>\n<li>A., 1. Added the underlined: \u201cIf the breast reconstruction has been successfully completed postmastectomy\/breast conserving surgery with implants and the enrollee chooses to enlarge or decrease in size their breast after a period of time, this is considered a cosmetic service and not a covered benefit in accordance with member\u2019s plan coverage.\u201d<\/li>\n<li>Eliminated B. \u201cScar revision is a covered service postmastectomy\/breast conserving surgery including donor site following flap reconstruction.\u201d<\/li>\n<li>Removed D. \u201cAutologous fat grafting during the reconstruction phase postmastectomy\/breast conserving surgery is a covered benefit.\u201d<\/li>\n<li>Added J. \u201cBreast reconstructive surgery to correct breast asymmetry is considered cosmetic EXCEPT\u2026\u201d and items 1-4.<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p><strong><br \/>\nGender Reassignment Surgery<\/strong><br \/>\n<em>Added the following procedure codes:<\/em><\/p>\n<ul>\n<li>19325 Mammoplasty, augmentation with prosthetic implant<\/li>\n<li>19328 Removal of intact Mammary implant<\/li>\n<li>19330 Removal of intact Mammary implant material<\/li>\n<li>19370 Open Periprosthetic capsulectomy<\/li>\n<li>19371 Periprosthetic capsulectomy<\/li>\n<li>19396 Preparation of Moulage for custom breast implant<\/li>\n<\/ul>\n<p><strong><br \/>\nInfertility Treatment<\/strong><\/p>\n<p>Recommended entire policy be reviewed due to significant changes.<\/p>\n<p><strong>Surgical Treatment of Gynecomastia<\/strong><\/p>\n<ul>\n<li>Added 2 new definitions<\/li>\n<li>Significant changes with \u201cCriteria for Approval\u201d for all product lines<\/li>\n<li>Added a new item under \u201cWhat is Not Covered\u201d\n<ul>\n<li>\u00a09. (new) Added: Gynecomastia surgery using liposuction as the sole surgical procedure<\/li>\n<\/ul>\n<\/li>\n<li>Removed ICD-10 Diagnosis section<\/li>\n<\/ul>\n<p><strong><br \/>\nArchived January 2020<\/strong><br \/>\nWearable Cardiac Defibrillator (e.g., LifeVest)<\/p>\n<p><em>*Please note new\/revised policies may not appear until closer to the effective date.<\/em><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Health New England\u2019s Clinicial Policies have been updated and can be found at healthnewengland.org\/providers\/resources. On the Resources page, click on &#8220;Behavioral Health\/Medical Policies&#8221; section to learn of the changes. Effective 4\/1\/2020 Hyperbaric Oxygen Therapy (Outpatient Services) Added 14 new definitions Made adjustments to the \u201cCriteria for Approval\u201d Removed B: \u201cRequests for HBO Therapy for the [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":5045,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"jetpack_post_was_ever_published":false,"_jetpack_newsletter_access":"","_jetpack_dont_email_post_to_subs":false,"_jetpack_newsletter_tier_id":0,"_jetpack_memberships_contains_paywalled_content":false,"_jetpack_memberships_contains_paid_content":false,"footnotes":"","jetpack_publicize_message":"","jetpack_publicize_feature_enabled":true,"jetpack_social_post_already_shared":true,"jetpack_social_options":{"image_generator_settings":{"template":"highway","default_image_id":0,"font":"","enabled":false},"version":2}},"categories":[92],"tags":[],"class_list":["post-5044","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-provider-newsletter"],"jetpack_publicize_connections":[],"jetpack_featured_media_url":"https:\/\/i0.wp.com\/hnetalk.com\/provider\/wp-content\/uploads\/2020\/02\/medical-director.jpg?fit=2133%2C1405","jetpack_sharing_enabled":true,"jetpack_shortlink":"https:\/\/wp.me\/p6ZZHB-1jm","_links":{"self":[{"href":"http:\/\/hnetalk.com\/provider\/wp-json\/wp\/v2\/posts\/5044","targetHints":{"allow":["GET"]}}],"collection":[{"href":"http:\/\/hnetalk.com\/provider\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"http:\/\/hnetalk.com\/provider\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"http:\/\/hnetalk.com\/provider\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"http:\/\/hnetalk.com\/provider\/wp-json\/wp\/v2\/comments?post=5044"}],"version-history":[{"count":4,"href":"http:\/\/hnetalk.com\/provider\/wp-json\/wp\/v2\/posts\/5044\/revisions"}],"predecessor-version":[{"id":5049,"href":"http:\/\/hnetalk.com\/provider\/wp-json\/wp\/v2\/posts\/5044\/revisions\/5049"}],"wp:featuredmedia":[{"embeddable":true,"href":"http:\/\/hnetalk.com\/provider\/wp-json\/wp\/v2\/media\/5045"}],"wp:attachment":[{"href":"http:\/\/hnetalk.com\/provider\/wp-json\/wp\/v2\/media?parent=5044"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"http:\/\/hnetalk.com\/provider\/wp-json\/wp\/v2\/categories?post=5044"},{"taxonomy":"post_tag","embeddable":true,"href":"http:\/\/hnetalk.com\/provider\/wp-json\/wp\/v2\/tags?post=5044"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}