{"id":5758,"date":"2020-11-04T20:42:17","date_gmt":"2020-11-04T20:42:17","guid":{"rendered":"http:\/\/hnetalk.com\/provider\/?p=5758"},"modified":"2020-11-04T21:32:08","modified_gmt":"2020-11-04T21:32:08","slug":"clinical-review-criteria-november-2020","status":"publish","type":"post","link":"http:\/\/hnetalk.com\/provider\/clinical-review-criteria-november-2020\/","title":{"rendered":"Clinical Review Criteria – November 2020"},"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

New Medical Policies (Effective 12\/1\/2020)<\/strong>
\nAzedra (iobenguane I 131)
\nNodify Lung Nodule Risk Assessment BDX-XL2 (Biodesix, Inc.)<\/p>\n

New Medical Policy (Effective 1\/1\/2021)<\/strong>
\nDeep Brain Stimulation Treatment for Essential Tremor and Parkinson\u2019s Disease<\/p>\n

Reviewed and Updated (Effective 12\/1\/2020<\/strong>
\nTreatment of Lipodystrophy Syndrome (LDS)
\n\u2022 Updated Criteria for Approval – Added \u201cCommercial, Medicare, Medicaid\u201d to the section title
\n\u2022 HCPC Codes – Deleted Code C9800
\n\u2022 CPT Codes – Deleted Codes 15878 and 15879, as policy is for facial lipodystrophy<\/p>\n

Surgical Management of Morbid Obesity<\/strong>
\n\u2022 Updated Criteria for Approval:
\no Criteria for Approval for Ages 18 and Over
\no Criteria for Approval for Adolescents Ages 13-17
\no Repeat Bariatric Surgery
\no Medicare
\n\u2022 What is Not Covered<\/p>\n

Contact Lenses<\/strong>
\n\u2022 Updated Definitions, Scleral Shell or Shield – Added \u201cIt functions as a protective barrier against tear evaporation. Used as an artificial support and a protective covering for diseased eye or sightless or shrunken eye.\u201d
\n\u2022 Updated Criteria for Approval<\/p>\n

Cochlear Implants, BAHA (Bone Anchored Hearing Aid), and ABI (Auditory Brainstem Implant)<\/strong>
\n\u2022 Changed name of policy to add ABI
\n\u2022 Updated Definitions: Added description of hybrid cochlear implant
\n\u2022 Added HNE adopted InterQual criteria (where applicable)
\n\u2022 Updated headings in several sections:
\nFrom: \u201cAdult Criteria for Approval of Cochlear Implant for Commercial\/MassHealth\u201d
\nTo: \u201cCriteria for Approval of Cochlear Implant for All Lines of Business\u201d<\/p>\n

From: \u201cIV., Criteria for Approval of Hybrid Cochlear Implant\/Hearing Aid Devices that include hearing aid integration into the external sound processor of the cochlear implant when all of the\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 below criteria are met:\u201d
\nTo: \u201cII., Criteria for Approval of Hybrid Cochlear Implant\/Hearing Aid Devices (such as the Nuclear Hybrid L24 Cochlear Implant System) that include hearing aid integration into the external
\nsound processor of the cochlear implant when all the below criteria are met:\u201d<\/p>\n

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

New Medical Policies (Effective 12\/1\/2020)<\/strong>
\nAzedra (iobenguane I 131)
\nNodify Lung Nodule Risk Assessment BDX-XL2 (Biodesix, Inc.)<\/p>\n

New Medical Policy (Effective 1\/1\/2021)<\/strong>
\nDeep Brain Stimulation Treatment for Essential Tremor and Parkinson\u2019s Disease<\/p>\n

Reviewed and Updated (Effective 12\/1\/2020<\/strong>
\n\u2022\u00a0<\/strong>Treatment of Lipodystrophy Syndrome (LDS)
\n\u2022 Updated Criteria for Approval – Added \u201cCommercial, Medicare, Medicaid\u201d to the section title
\n\u2022 HCPC Codes – Deleted Code C9800
\n\u2022 CPT Codes – Deleted Codes 15878 and 15879, as policy is for facial lipodystrophy<\/p>\n

Surgical Management of Morbid Obesity<\/strong>
\n\u2022 Updated Criteria for Approval:
\no Criteria for Approval for Ages 18 and Over
\no Criteria for Approval for Adolescents Ages 13-17
\no Repeat Bariatric Surgery
\no Medicare
\n\u2022 What is Not Covered<\/p>\n

Contact Lenses<\/strong>
\n\u2022 Updated Definitions, Scleral Shell or Shield – Added \u201cIt functions as a protective barrier against tear evaporation. Used as an artificial support and a protective covering for diseased eye or sightless or shrunken eye.\u201d
\n\u2022 Updated Criteria for Approval<\/p>\n

Cochlear Implants, BAHA (Bone Anchored Hearing Aid), and ABI (Auditory Brainstem Implant)<\/strong>
\n\u2022 Changed name of policy to add ABI
\n\u2022 Updated Definitions: Added description of hybrid cochlear implant
\n\u2022 Added HNE adopted InterQual criteria (where applicable)
\n\u2022 Updated headings in several sections:
\nFrom: \u201cAdult Criteria for Approval of Cochlear Implant for Commercial\/MassHealth\u201d
\nTo: \u201cCriteria for Approval of Cochlear Implant for All Lines of Business\u201d<\/p>\n

From: \u201cIV., Criteria for Approval of Hybrid Cochlear Implant\/Hearing Aid Devices that include hearing aid integration into the external sound processor of the cochlear implant when all of the
\nbelow criteria are met:\u201d
\nTo: \u201cII., Criteria for Approval of Hybrid Cochlear Implant\/Hearing Aid Devices (such as the Nuclear Hybrid L24 Cochlear Implant System) that include hearing aid integration into the external sound
\nprocessor of the cochlear implant when all the below criteria are met:\u201d<\/p>\n

From: \u201cVI., AUDITORY BRAINSTEM IMPLANT (ABI) is covered for:\u201d
\nTo: \u201cIV., Auditory Brainstem Implant (ABI), unilateral, is covered for\u201d<\/p>\n

\u2022 Updated What is Not Covered
\n\u2022 Updated HCPCS and Requirements
\no “Associated HCPCS that do not require PA\u201d Changed to \u201cAssociated HCPCS\u201d
\no Removed code L8613 (not configured for PA)
\no Added L8627, L8628, L8629 under cochlear devices (these codes have IQ criteria and are on config list)
\no Removed code L8691 (not configured for PA)<\/p>\n

Abdominal Panniculectomy and Removal of Excess Skin<\/strong>
\n\u2022 Changed name of policy to add \u201cand Removal of Excess Skin\u201d
\n\u2022 Updated Criteria for Approval: Commercial and Medicare
\n\u2022 Updated Criteria for Approval of MassHealth member \u2013 (Reviewed on a case-by-case basis)
\n\u2022 Updated CPT Codes: Added CPT codes in table form<\/p>\n

Formula and Enteral Nutrition<\/strong>
\n\u2022 Staff wanted clarification of policy as it technically was only for MassHealth – now LOB has been added
\n\u2022 Attached to policy is a link for Northwood’s criteria, which HNE will be using for MassHealth reviews
\n\u2022 Added Commercial criteria info, for use with all Commercial policies
\n\u2022 Added Medicare link for Medicare members<\/p>\n

Intacs Corneal Implants (Intrastromal Corneal Ring Segments<\/strong>
\n\u2022 Updated Criteria for Approval
\n\u2022 Updated What is Not Covered<\/p>\n

Endothelial Keratoplasty (also known as Posterior Lamellar Keratoplasty)<\/strong>
\n\u2022 Health New England has adopted InterQual criteria
\n\u2022 HNE Nurse Reviewers use InterQual through Medecision\u2019s Aerial Medical Management System<\/p>\n

Percutaneous Left Atrial Appendage Closure<\/strong>
\n\u2022 Updated Criteria for Approval
\n\u2022 Updated What is Not Covered<\/p>\n

Balloon Sinus Dilation of the Eustachian Tubes<\/strong>
\n\u2022 Code Correction – HCPC Code should be C9745 (NOT C7945)<\/p>\n

Long-Term 30-Day Cardiac Monitoring<\/strong>
\n\u2022 CPT Codes now included – 93228 which requires PA; and 93229 which does not require PA<\/p>\n

Therapeutic Shoe and Orthotic Coverage<\/strong>
\n\u2022 HCPCS codes added to policy<\/p>\n

Orthognathic Surgery<\/strong>
\n\u2022 CPT codes added to policy<\/p>\n

Rhinoplasty<\/strong>
\n\u2022 CPT codes added to policy<\/p>\n

Reconstructive Repair of Pectus Excavatum or Pectus Carinatum<\/strong>
\n\u2022 CPT codes added to policy<\/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. New Medical Policies (Effective 12\/1\/2020) Azedra (iobenguane I 131) Nodify Lung Nodule Risk Assessment BDX-XL2 (Biodesix, Inc.) New Medical Policy (Effective 1\/1\/2021) Deep Brain Stimulation Treatment […]<\/p>\n","protected":false},"author":1,"featured_media":0,"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-5758","post","type-post","status-publish","format-standard","hentry","category-provider-newsletter"],"jetpack_publicize_connections":[],"jetpack_featured_media_url":"","jetpack_sharing_enabled":true,"jetpack_shortlink":"https:\/\/wp.me\/p6ZZHB-1uS","_links":{"self":[{"href":"http:\/\/hnetalk.com\/provider\/wp-json\/wp\/v2\/posts\/5758","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=5758"}],"version-history":[{"count":1,"href":"http:\/\/hnetalk.com\/provider\/wp-json\/wp\/v2\/posts\/5758\/revisions"}],"predecessor-version":[{"id":5759,"href":"http:\/\/hnetalk.com\/provider\/wp-json\/wp\/v2\/posts\/5758\/revisions\/5759"}],"wp:attachment":[{"href":"http:\/\/hnetalk.com\/provider\/wp-json\/wp\/v2\/media?parent=5758"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"http:\/\/hnetalk.com\/provider\/wp-json\/wp\/v2\/categories?post=5758"},{"taxonomy":"post_tag","embeddable":true,"href":"http:\/\/hnetalk.com\/provider\/wp-json\/wp\/v2\/tags?post=5758"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}