{"id":6142,"date":"2020-12-14T15:50:40","date_gmt":"2020-12-14T15:50:40","guid":{"rendered":"http:\/\/hnetalk.com\/provider\/?p=6142"},"modified":"2020-12-14T15:52:47","modified_gmt":"2020-12-14T15:52:47","slug":"clinical-review-criteria-december-2020","status":"publish","type":"post","link":"http:\/\/hnetalk.com\/provider\/clinical-review-criteria-december-2020\/","title":{"rendered":"Clinical Review Criteria – December 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

Please note, new\/revised policies may not appear until closer to the effective date. <\/em><\/p>\n

Reviewed and Updated<\/strong> (Effective date of 2\/1\/2021 )<\/p>\n

Chimeric Antigen Receptor T-Cell Therapy<\/strong> (CAR-T Cell Therapy): Kymriah and Yescarta
\n\u2022 Expanded definition on Kymriah and Yescarta
\n\u2022 Updated \u201cCriteria for Approval\u201d<\/p>\n

Bronchial Thermoplasty<\/strong>
\n\u2022 Updated \u201cCriteria for Approval\u201d
\n\u2022 Updated \u201cWhat is Not Covered\u201d<\/p>\n

Artificial Intervertebral Cervical Disc<\/strong>
\n\u2022 Changed medical criteria disclaimer to InterQual disclaimer
\n\u2022 Updated \u201cCriteria for Approval\u201d
\n\u2022 Removed \u201cWhat is Not Covered\/Contraindicated\u201d
\n\u2022 Updated CPT Codes:
\n– Removed CPT codes 22861 and 22864<\/p>\n

Drug Testing<\/strong>
\n\u2022 Under \u201cScope,\u201d Behavioral Health (BH) was added
\n\u2022 Updated definitions
\n\u2022 Updated \u201cCriteria For Approval of Urine Drug Testing\u201d
\n\u2022 Updated \u201cWhat is Not Covered\u201d<\/p>\n

Gastric Electrical Stimulation<\/strong> (GES) (Enterra Therapy System)
\n\u2022 Updated Section II., \u201cFor Continuation of Treatment of somatostatin receptor-positive gastroenteropancreatic neuroendocrine tumors \u2026\u201d
\no Added the underlined to the statement:
\nFor Continuation of Treatment of somatostatin receptor-positive gastroenteropancreatic neuroendocrine tumors (GEP-NETs), must meet above criteria and criteria listed below and is limited to
\n4 doses administered no less than 8 weeks apart.
\n\u2022 Letter A. was added along with 1. through 5.:
\no Patient must also meet the following criteria for continuation of treatment:
\n-No recurrent grade 2, 3, or 4 thrombocytopenia
\n-No recurrent grade 3 or 4 anemia and neutropenia
\n-No recurrent hepatotoxicity
\n-No recurrent grade 3 or 4 non-hematologic toxicity
\n-Renal toxicity requiring a treatment delay of 4 months or longer
\n\u2022 Updated \u201cWhat is Not Covered\/Contraindications\u201d
\nB.: Changed the creatinine clearance from < 50 ml\/minute to < 30 ml\/minute<\/p>\n

Skin and Soft Tissue Substitutes<\/strong>
\n\u2022 Updated III., Non-Covered Codes (Experimental and Investigational)
\nQ4165 and Q4166 were corrected.<\/p>\n

Sacral Nerve Stimulation and Electrical Percutaneous Tibial Nerve Stimulation<\/strong>
\n\u2022 Updated definitions
\n\u2022 Updated \u201cCriteria for Approval\u201d
\n\u2022 Updated IV., Contraindications for PTNS include ANY of the following:
\nAdded letter C.: Member with neurogenic overactive bladder syndrome\/neurogenic lower urinary tract dysfunction; OR
\n\u2022 Updated CPT Codes:
\no Added 64566 Posterior tibial neurostimulation, percutaneous needle electrode, single treatment, includes programming
\no Added 4 E & I codes including descriptions<\/p>\n

Home Health Care Services for MassHealth<\/strong>
\n\u2022 Updated \u201cCriteria for Approval\u201d
\n\u2022 Updated II., Applicable Codes
\nApplicable codes moved up into policy under Section II.<\/p>\n

Corneal Cross Linking<\/strong>
\n\u2022 Updated \u201cDefinitions\u201d
\n\u2022 I., For Commercial Policies only:
\nA.: Added the underlined:\u00a0\u201cProgressive keratoconus diagnosed by keratometry and corneal mapping\u201d
\n\u2022 Updated \u201cCriteria for Approval\u201d
\n\u2022 Updated \u201cWhat is not Covered\u201d<\/p>\n

Outpatient Physical and Occupational Therapy<\/strong>
\n\u2022 Updated \u201cDefinitions\u201d
\n\u2022 Updated \u201cCriteria for Approval\u201d
\n\u2022 Medicare Advantage Plans, 2.:
\no Added the underlined:
\nFor rehabilitation services in a skilled nursing facility (SNF), the evaluation and treatment plan must be submitted along with the prior authorization request. An authorization is required for any
\nservices in an SNF. Member must be showing progress with rehabilitation in order to continue with therapy. Generally, the rehabilitation services are provided 2-3x\/week to be considered under Medicare Part B.
\no Added CMS link to coverage database<\/p>\n

Medicaid Plans:<\/strong>
\no Added MassHealth links for PT and OT
\no 2.: Added the underlined word:
\nFor rehabilitation services in a skilled nursing facility (SNF), the evaluation and treatment plan must be submitted along with the prior authorization request. An authorization is required for any services in an SNF. Member must be showing progress with rehabilitation in order to continue with therapy.
\n\u2022 Updated \u201cCoverage Guidelines\u201d
\n\u2022 Updated \u201cRequired Documentation\u201d
\n\u2022 Updated \u201cWhat is Not Covered\u201d<\/p>\n

Upper Airway Stimulation Device (UAS)\/Hypoglossal Nerve Stimulation<\/strong> (HGNS) (Inspire)
\n\u2022 Updated \u201cCriteria for Approval\u201d for Commercial members<\/p>\n

Reviewed with no or substantive changes<\/strong> (Effective date of 2\/1\/2021)
\n\u2022 Knee Arthroplasty and Knee Arthroscopy for MassHealth
\n\u2022 Family Stabilization Team
\n\u2022 New Medical Policies (Effective date of 2\/1\/2021)
\n\u2022 Non-Covered, Experimental and Investigational Services
\n\u2022 Water Vapor Thermal Therapy (Rezum)
\n\u2022 Antibody Testing for Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) [Coronavirus Disease (COVID-19)]<\/p>\n

 <\/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. Please note, new\/revised policies may not appear until closer to the effective date. Reviewed and Updated (Effective date of 2\/1\/2021 ) Chimeric Antigen Receptor T-Cell Therapy […]<\/p>\n","protected":false},"author":1,"featured_media":4758,"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-6142","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\/06\/close_up_hand_on_laptop_keyboard.jpg?fit=2122%2C1415","jetpack_sharing_enabled":true,"jetpack_shortlink":"https:\/\/wp.me\/p6ZZHB-1B4","_links":{"self":[{"href":"http:\/\/hnetalk.com\/provider\/wp-json\/wp\/v2\/posts\/6142","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=6142"}],"version-history":[{"count":5,"href":"http:\/\/hnetalk.com\/provider\/wp-json\/wp\/v2\/posts\/6142\/revisions"}],"predecessor-version":[{"id":6147,"href":"http:\/\/hnetalk.com\/provider\/wp-json\/wp\/v2\/posts\/6142\/revisions\/6147"}],"wp:featuredmedia":[{"embeddable":true,"href":"http:\/\/hnetalk.com\/provider\/wp-json\/wp\/v2\/media\/4758"}],"wp:attachment":[{"href":"http:\/\/hnetalk.com\/provider\/wp-json\/wp\/v2\/media?parent=6142"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"http:\/\/hnetalk.com\/provider\/wp-json\/wp\/v2\/categories?post=6142"},{"taxonomy":"post_tag","embeddable":true,"href":"http:\/\/hnetalk.com\/provider\/wp-json\/wp\/v2\/tags?post=6142"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}