{"id":5459,"date":"2020-07-02T13:03:56","date_gmt":"2020-07-02T13:03:56","guid":{"rendered":"http:\/\/hnetalk.com\/provider\/?p=5459"},"modified":"2020-07-02T13:11:56","modified_gmt":"2020-07-02T13:11:56","slug":"july-2020-clinical-review-criteria","status":"publish","type":"post","link":"http:\/\/hnetalk.com\/provider\/july-2020-clinical-review-criteria\/","title":{"rendered":"July 2020 – Clinical Review Criteria"},"content":{"rendered":"

Health New England\u2019s Clinical Policies have been updated and can be found at healthnewengland.org\/providers\/resources<\/a>. Once on the Resources page, click on Behavioral Health\/Medical Policies to learn of the changes.*<\/p>\n

MEDICAL POLICIES:<\/h2>\n

Updated Policies Effective 9\/1\/2020
\n<\/em>
\nKnee Braces<\/strong>
\n\u2022 Definition changes with Prefabricated Braces<\/p>\n

Changed From:<\/em>
\nPrefabricated Braces: (L1810-L1833, L1836, L1843, L1845, L1847, L1850 and L1852) Generally attempted prior to using a custom fitted orthosis. These braces are off-the-shelf and may be purchased in stores.<\/p>\n

Changed To:<\/em>
\nPrefabricated Braces: (L1810, L1812, L1820, L1830 – L1833, L1836, L1843, L1845, L1847, L1848, L1850, L1851, L1852) Generally attempted prior to using a custom fitted orthosis. These braces are off-the-shelf and may be purchased in stores. These braces come in a selection of sizes (small, medium, large, extra-large) and only require measurements and a sizing chart for fitting. Minimal adjustments will be made.
\n\u2022 Updated Criteria for Approval
\n\u2022 Updated What is Not Covered<\/p>\n

Speech Therapy<\/strong>
\n\u2022 Updated Criteria for Approval
\n\u2022 Required Documentation for Initial Determination
\n\u2022 Update What is Not Covered<\/p>\n

Total Ankle Replacement<\/strong>
\n\u2022 Health New England has adopted InterQual criteria. Health New England Nurse reviewers use InterQual through Medecision\u2019s Aerial medical management system.
\n\u2022 InterQual criteria are available upon request by members and providers.<\/p>\n

Proton Beam Therapy<\/strong>
\n\u2022 Health New England has adopted InterQual criteria. Health New England Nurse reviewers use InterQual through Medecision\u2019s Aerial medical management system.
\n\u2022 InterQual criteria are available upon request by members and providers.<\/p>\n

Laser-Assisted Uvulopalatoplasty or Uvulopalatopharyngoplasty<\/strong>
\n\u2022 Health New England has adopted InterQual criteria. Health New England Nurse reviewers use InterQual through Medecision\u2019s Aerial medical management system.
\n\u2022 InterQual criteria are available upon request by members and providers.
\n\u2022 Updated Criteria for Approval.<\/p>\n

Upper Airway Stimulation Device (UAS)\/Hypoglossal Nerve Stimulation (HGNS) (Inspire)<\/strong>
\n\u2022 Updated Criteria for Medicare Approval<\/p>\n

From:<\/em>
\n(Medicare is reimbursing the cost of Inspire therapy based on medical necessity in many geographies across the United States. An Inspire trained physician can discuss Medicare coverage in your area during an initial consultation.) There is no NCD.
\nTo:<\/em>
\nAs of 4\/1\/2020, Medicare covers hypoglossal nerve stimulation for treatment of sleep apnea. LCD is L38387. Criteria for medical necessity is located at the CMS link here<\/a>.<\/p>\n

Transplants and Ventricular Assist Devices<\/strong>
\n\u2022 Added Medicare approval information with Ventricular Assist Devices (VAD) and facilities
\n\u2022 Updated What is Not Covered<\/p>\n

Reconstructive Breast Surgery Following Mastectomy or Breast Conserving Surgery<\/strong>
\n\u2022 Additional CPT Codes:
\n15769
\nGrafting of autologous soft tissue, other, harvested by direct excision (e.g., fat, dermis, fascia)
\n15771
\nGrafting of autologous fat harvested by liposuction technique to trunk, breasts, scalp, arms, and\/or legs; 50 cc or less injectate
\n15772
\nGrafting of autologous fat harvested by liposuction technique to trunk, breasts, scalp, arms, and\/or legs; each additional 50 cc injectate, or part thereof (List separately in addition to code for primary procedure.)
\n15773
\nGrafting of autologous fat harvested by liposuction technique to face, eyelids, mouth, neck, ears, orbits, genitalia, hands and\/or feet; 25 cc or less injectate
\n15774
\nGrafting of autologous fat harvested by liposuction technique to face, eyelids, mouth, neck, ears, orbits, genitalia, hands and\/or feet; 25 cc or less injectate: each additional 25 cc injectate, or part thereof<\/p>\n

Archived Policies<\/h2>\n

\u2022 Total Hip Resurfacing<\/p>\n

*Please note new\/revised policies may not appear until closer to the effective date.<\/em><\/p>\n","protected":false},"excerpt":{"rendered":"

Health New England\u2019s Clinical Policies have been updated and can be found at healthnewengland.org\/providers\/resources. Once on the Resources page, click on Behavioral Health\/Medical Policies to learn of the changes.* MEDICAL POLICIES: Updated Policies Effective 9\/1\/2020 Knee Braces \u2022 Definition changes with Prefabricated Braces Changed From: Prefabricated Braces: (L1810-L1833, L1836, L1843, L1845, L1847, L1850 and L1852) […]<\/p>\n","protected":false},"author":1,"featured_media":4692,"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-5459","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\/2019\/05\/GettyImages-519123626.jpg?fit=5400%2C3600","jetpack_sharing_enabled":true,"jetpack_shortlink":"https:\/\/wp.me\/p6ZZHB-1q3","_links":{"self":[{"href":"http:\/\/hnetalk.com\/provider\/wp-json\/wp\/v2\/posts\/5459","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=5459"}],"version-history":[{"count":2,"href":"http:\/\/hnetalk.com\/provider\/wp-json\/wp\/v2\/posts\/5459\/revisions"}],"predecessor-version":[{"id":5462,"href":"http:\/\/hnetalk.com\/provider\/wp-json\/wp\/v2\/posts\/5459\/revisions\/5462"}],"wp:featuredmedia":[{"embeddable":true,"href":"http:\/\/hnetalk.com\/provider\/wp-json\/wp\/v2\/media\/4692"}],"wp:attachment":[{"href":"http:\/\/hnetalk.com\/provider\/wp-json\/wp\/v2\/media?parent=5459"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"http:\/\/hnetalk.com\/provider\/wp-json\/wp\/v2\/categories?post=5459"},{"taxonomy":"post_tag","embeddable":true,"href":"http:\/\/hnetalk.com\/provider\/wp-json\/wp\/v2\/tags?post=5459"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}