{"id":6851,"date":"2021-09-30T16:33:36","date_gmt":"2021-09-30T16:33:36","guid":{"rendered":"http:\/\/hnetalk.com\/provider\/?p=6851"},"modified":"2021-09-30T16:46:30","modified_gmt":"2021-09-30T16:46:30","slug":"october-2021-clinical-review-criteria","status":"publish","type":"post","link":"http:\/\/hnetalk.com\/provider\/october-2021-clinical-review-criteria\/","title":{"rendered":"October 2021 Clinical Review Criteria"},"content":{"rendered":"

Health New England reviews clinical policies and updates accordingly. These policies reside at healthnewengland.org\/Providers\/Resources<\/a>. Once on the Resources page, click on Behavioral Health\/Medical Policies<\/strong> to learn more.<\/p>\n

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

Medical Policy\u00a0<\/strong>Title<\/strong><\/td>\n

 <\/p>\n

Policy\u00a0<\/strong>Number<\/strong><\/td>\n

 <\/p>\n

Description of Change<\/strong><\/td>\n

 <\/p>\n

Effective\u00a0<\/strong>Date<\/strong><\/td>\n

 <\/p>\n

LOB\u00a0<\/strong>Affected<\/strong><\/td>\n

 <\/p>\n

Policy Type<\/strong><\/td>\n<\/tr>\n

Contact Lenses<\/td>\nUM303POL<\/td>\n\u00b7\u00a0 Definitions<\/p>\n

Added additional information to Corneal contact lens and Scleral contact lens, and added 4 new definitions<\/p>\n

\u00b7\u00a0 I., General Criteria for Approval<\/p>\n

o\u00a0\u00a0 Added Medicare and Commercial to the heading<\/p>\n

o\u00a0 \u00a0B., 2.:\u00a0 Removed \u201cMassHealth and\u201d from statement<\/p>\n

 <\/p>\n

\u00b7\u00a0 III., What is Not Covered:\u00a0 Medicare and Commercial<\/p>\n

o\u00a0\u00a0 New (formerly V.)<\/p>\n

o\u00a0\u00a0 Updated numbering on sections that follow<\/p>\n

\u00b7\u00a0 \u00a0IV., Medically Necessary for MassHealth<\/u> Members<\/p>\n

o\u00a0\u00a0 Formerly III.<\/p>\n

o\u00a0\u00a0 Letter F. added and 4 statements below it<\/p>\n

o\u00a0\u00a0 Added \u201cFor additional information:\u201d and the Mass.gov link<\/p>\n

\u00b7\u00a0 VI., What is Not Covered under MassHealth<\/p>\n

o\u00a0\u00a0 Added VI., including 7 items<\/p>\n

\u00b7\u00a0 VII., Eyeglasses<\/p>\n

o\u00a0\u00a0 Added VII., including 3 items<\/p>\n

\u00b7\u00a0 Added table of HCPCS<\/p>\n

\u00b7\u00a0 Added table of CPT Codes, including statement \u201cNO PA **Covered only when member meets criteria for contact lenses**\u201d<\/p>\n

\u00b7\u00a0 Source\/Citation Section<\/p>\n

o\u00a0\u00a0 Sources and citations retrieved and updated<\/p>\n

o\u00a0\u00a0 Added Medicare Coverage Database citation<\/p>\n

o\u00a0\u00a0 Eliminated Yoo, D citation<\/p>\n

o\u00a0\u00a0 Added 2 citations re:\u00a0 Absorptive lenses<\/p>\n

 <\/td>\n

12\/1\/2021<\/td>\nCommercial<\/p>\n

Medicare<\/p>\n

Medicaid<\/td>\n

Medical<\/td>\n<\/tr>\n
Percutaneous Left Atrial Appendage Closure<\/td>\nUM633POL<\/td>\n\u00b7\u00a0 Definitions:\u00a0 Corrected link for CHA2DS2-VASc score<\/p>\n

\u00b7\u00a0 Source\/Citation Section:\u00a0 Confirmed citations and added 2 new citations<\/p>\n

 <\/td>\n

12\/1\/2021<\/td>\nCommercial<\/p>\n

Medicare<\/p>\n

Medicaid<\/td>\n

Medical<\/td>\n<\/tr>\n
Azedra<\/p>\n

(iobenguane I 131)<\/td>\n

UM726POL<\/td>\n\u00b7\u00a0 Definitions:\u00a0 Added to Azedra:\u00a0 \u201cRadioactive therapeutic agent\u201d<\/p>\n

\u00b7\u00a0 I., Criteria for Approval of Azedra<\/p>\n

A., 5. was added:\u00a0 \u201cMember has had an administration of inorganic iodine.\u201d<\/p>\n

\u00b7 III., What is Not Covered<\/p>\n

o\u00a0\u00a0 D. was added:\u00a0 \u201cMembers on concomitant drugs that reduce catecholamine uptake or deplete catecholamine stores\u201d<\/p>\n

o\u00a0\u00a0 E. was added:\u00a0 \u201cSevere renal impairment (creatinine clearance <30)\u201d<\/p>\n

\u00b7\u00a0 Source\/Citation Section:\u00a0 Sources were confirmed and updated.<\/p>\n

 <\/td>\n

12\/1\/2021<\/td>\nCommercial<\/p>\n

Medicare<\/p>\n

Medicaid<\/td>\n

Medical<\/td>\n<\/tr>\n
Cochlear Implants, BAHA (Bone-Anchored Hearing Aid), and ABI (Auditory Brainstem Implant)<\/td>\nUM201POL<\/td>\n\u00b7 Definitions:<\/p>\n

Added Unilateral Hearing Loss (UHL), Single-Sided Deafness (SSD), Soundbites; and related definitions<\/p>\n

\u00b7 I., Criteria for Approval<\/p>\n

Changed statement<\/p>\n

From:\u00a0 <\/em>Criteria for Approval of Cochlear Implant \u2013 for All Lines of Business:<\/p>\n

To:\u00a0 \u00a0\u00a0\u00a0\u00a0 <\/em>Criteria for Approval of Initial Cochlear Implant Only (including unilateral hearing loss).\u00a0 See below for information regarding replacement \u2013 for All Lines of Business:<\/p>\n

\u00b7\u00a0 II., E.<\/p>\n

Added the underlined:<\/p>\n

E., Member displays ANY of<\/u> the below hearing thresholds:<\/p>\n

\u00b7 V., What is Not Covered<\/p>\n

o\u00a0\u00a0 Deleted B.:<\/p>\n

B., Cochlear implantation, including hybrid implants, as a treatment for patients with unilateral hearing loss with or without tinnitus is investigational.<\/p>\n

o\u00a0\u00a0 H. was added<\/p>\n

o\u00a0\u00a0 I. was added<\/p>\n

\u00b7\u00a0 Source\/Citation Section:<\/p>\n

All citations confirmed<\/p>\n

\u00b7\u00a0 Additional Resources:<\/p>\n

All confirmed<\/p>\n

 <\/td>\n

12\/1\/2021<\/td>\nCommercial<\/p>\n

Medicare<\/p>\n

Medicaid<\/td>\n

Medical<\/td>\n<\/tr>\n
Endothelial Keratoplasty<\/td>\nUM430POL<\/td>\n\u00b7\u00a0 \u00a0CPT Codes:\u00a0 Added \u201c(Confirmed on 5\/13\/2021 \u2013 both are on Y\/N list)\u201d<\/p>\n

\u00b7\u00a0 Source\/Citation Section:\u00a0 All confirmed with 1 new one added<\/p>\n

 <\/td>\n

12\/1\/2021<\/td>\nCommercial<\/p>\n

Medicare<\/p>\n

Medicaid<\/td>\n

Medical<\/p>\n

 <\/td>\n<\/tr>\n

Hydrogen Breath Testing (HBT)<\/td>\nUM672POL<\/td>\n\u00b7\u00a0 II., Authorization<\/p>\n

A.:\u00a0 Added the underlined:<\/p>\n

\u201cNo prior authorization is required for HBT.\u00a0 Policy is in place to support claim-confirmed 5\/13\/2021 by JS<\/u>.\u201d<\/p>\n

\u00b7\u00a0 Source\/Citation Section:\u00a0 All citations confirmed<\/p>\n

 <\/td>\n

12\/1\/2021<\/td>\nCommercial<\/p>\n

Medicare<\/p>\n

Medicaid<\/td>\n

Medical<\/td>\n<\/tr>\n
Corneal Implants (Intrastromal Corneal Ring Segments)<\/td>\nUM687POL<\/td>\n\u00b7 Definitions:\u00a0 Added Intrastromal Corneal Ring Segments (ICRS)<\/p>\n

\u00b7\u00a0 Source\/Citation Section:\u00a0 All sources and citations were retrieved and confirmed; one new source added.<\/p>\n

 <\/td>\n

12\/1\/2021<\/td>\nCommercial<\/p>\n

Medicare<\/p>\n

Medicaid<\/td>\n

Medical<\/td>\n<\/tr>\n
Abdominal Panniculectomy and Removal of Excess Skin<\/td>\nUM238POL<\/td>\n\u00b7\u00a0 I., Criteria for Approval:\u00a0 Commercial and Medicare<\/p>\n

o\u00a0\u00a0 Added C.:\u00a0 \u201cThe member is 18 years of age or older on the date of services AND\u201d<\/p>\n

o\u00a0\u00a0 With the addition of C., the remaining lettering in this section was updated.<\/p>\n

o\u00a0\u00a0 E. (formerly D.):\u00a0 Corrected the spelling of the words redundant and subcutaneous<\/p>\n

\u00b7\u00a0 III., Required Documentation<\/p>\n

Formerly V. including A. thru F.\u00a0 Moved up from further in the document, renamed III.<\/p>\n

\u00b7\u00a0 \u00a0IV., Criteria for Approval of MassHealth member.\u00a0 Follow link below.\u00a0 (Reviewed on a case-by-case basis)<\/p>\n

o\u00a0\u00a0 Formerly III., changed to new IV., MassHealth link added<\/p>\n

o\u00a0\u00a0 Deleted residual information under MassHealth criteria:\u00a0 A-J<\/p>\n

\u00b7\u00a0 Former IV. eliminated<\/p>\n

\u00b7\u00a0 CPT Codes:\u00a0 Confirmed all codes on Y\/N list<\/p>\n

\u00b7\u00a0 Source\/Citation Section<\/p>\n

o\u00a0\u00a0 Confirmed all citations<\/p>\n

o\u00a0\u00a0 Added:\u00a0 \u201cMassHealth Guidelines for Medical Necessity Determination for Excision of Excessive Skin and\u00a0 Subcutaneous Tissue, Retrieved April 27, 2021, from: https:\/\/www.mass.gov\/guides\/masshealth-guidelines-for-medical-necessity-determination-for-excision-of-excessive-skin-and<\/a><\/p>\n

o\u00a0\u00a0 Confirmed above link ends with \u201cand\u201d<\/p>\n

 <\/td>\n

12\/1\/2021<\/td>\nCommercial<\/p>\n

Medicare<\/p>\n

Medicaid<\/td>\n

Medical<\/td>\n<\/tr>\n
Surgical Management of Morbid Obesity<\/td>\nUM061POL<\/td>\n\u00b7 I., Criteria for Approval for Ages 18 and Over:<\/p>\n

A.<\/p>\n

o\u00a0\u00a0 Added the underlined to the 3rd<\/sup> bullet:<\/p>\n

\u00b7\u00a0 \u00a0\u201cdocumented enrollment in a program that provides multidisciplinary evaluation and includes behavioral health, nutrition and medical management pre-op within 6 months prior to surgery <\/u>and post-op\u201d<\/p>\n

o\u00a0\u00a0 Added the underlined after 7th<\/sup> bullet after OR:<\/p>\n

\u00b7\u00a0 \u00a0 \u201cevidence of fatty liver disease (non-alcoholic fatty liver disease (NAFLD)<\/u>\u201d<\/p>\n

B.\u00a0\u00a0 Original statement #1. was deleted, with the following statement added in its place:<\/p>\n

1.\u00a0\u00a0 \u201cDocumentation from the treating surgeon attesting that the member meets criteria and believes the member is likely to benefit from surgery.\u00a0 AND<\/strong>\u201d<\/p>\n

\u00b7\u00a0 II., Criteria for Approval for Adolescents
\nB.<\/p>\n

o\u00a0\u00a0 Bullet 2:\u00a0 Added \u201cApnea Hypopnea Index\u201d<\/p>\n

o\u00a0\u00a0 Bullet 3:\u00a0 Added \u201c(Non-alcoholic Steatohepatitis)\u201d<\/p>\n

\u00b7\u00a0 III., Repeat Bariatric Surgery<\/p>\n

E.\u00a0\u00a0 Added E., \u201cMajor 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\u201d<\/p>\n

 <\/p>\n

\u00b7\u00a0 \u00a0IV., Medicare:<\/p>\n

o\u00a0\u00a0 Added \u201cLCD is followed for review.\u201d to the heading<\/p>\n

o\u00a0\u00a0 Added Medicare link<\/p>\n

o\u00a0\u00a0 Removed statements A., B. and C., and corresponding sub-statements<\/p>\n

\u00b7\u00a0 V., Required Documentation<\/p>\n

From:<\/em>\u00a0 Clinical notes referring to all of the above<\/p>\n

\u00a0To:<\/em>\u00a0 Clinical notes documenting all of the above<\/p>\n

\u00a0<\/em>\u00b7\u00a0 \u00a0VI., What is Not Covered<\/p>\n

F., Added the following 8 bullets<\/p>\n

\u00b7\u00a0 \u00a0Vertical Banded Gastroplasty (VBG)<\/p>\n

\u00b7\u00a0 \u00a0Biliopancreatic diversion (BPD)\u00a0 (BMC)<\/p>\n

\u00b7\u00a0 Laparoscopic gastric plication or laparoscopic greater curvature plication<\/p>\n

\u00b7\u00a0 Roux-en-Y gastric bypass (short limb or long limb) combined with simultaneous gastric banding<\/p>\n

\u00b7\u00a0 When used for GERD<\/p>\n

\u00b7\u00a0 Duodenal switch with single anastomosis<\/p>\n

\u00b7\u00a0 Parietal cell separating gastrojejunostomy<\/p>\n

\u00b7\u00a0 Two-stage bariatric surgery procedures<\/p>\n

\u00b7\u00a0 CPT Codes:\u00a0 Added \u201cNO PA\u201d to the following codes:<\/p>\n\n\n\n\n\n\n\n\n\n\n
43771 NO PA<\/strong><\/td>\n<\/tr>\n
43772 NO PA<\/strong><\/td>\n<\/tr>\n
43773 NO PA<\/strong><\/td>\n<\/tr>\n
43774 NO PA<\/strong><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

\u00b7\u00a0 Source\/Citation Section:\u00a0 All citations confirmed, with 3 added<\/p>\n

 <\/td>\n

12\/1\/2021<\/td>\nCommercial<\/p>\n

Medicare<\/p>\n

Medicaid<\/td>\n

Medical<\/td>\n<\/tr>\n
Nodify Lung Nodule Risk Assessment BDX-XL2 (Biodesix, Inc.)<\/td>\nUM751POL<\/td>\n\u00b7\u00a0 I., Criteria for Approval Medicare<\/u> Only:<\/p>\n

B.:\u00a0 Corrected the Medicare link<\/p>\n

\u00b7\u00a0 Source\/Citation Section:<\/p>\n

Citations confirmed and corrected if needed (#5)<\/p>\n

 <\/td>\n

12\/1\/2021<\/td>\nMedicare<\/p>\n

 <\/td>\n

Medical<\/td>\n<\/tr>\n
Treatment of Lipodystrophy Syndrome (LDS)<\/td>\nUM389POL<\/td>\n\u00b7\u00a0 HCPC Codes and CPT Codes:\u00a0 Confirmed on Y\/N list<\/p>\n

\u00b7\u00a0 Source\/Citation Section:\u00a0 Confirmed with 1 new citation added<\/p>\n

 <\/td>\n

12\/1\/2021<\/td>\nCommercial<\/p>\n

Medicare<\/p>\n

Medicaid<\/td>\n

Medical<\/td>\n<\/tr>\n
Deep Brain stimulation Treatment for Essential Tremor and Parkinson\u2019s Disease<\/td>\nUM750POL<\/td>\n\u00b7 I., Criteria for Approval<\/p>\n

Added \u201cAll Lines of Business\u201d<\/p>\n

\u00b7\u00a0 CPT Codes:<\/p>\n

o\u00a0\u00a0 Added \u201c(Confirmed all on Y\/N List)\u201d<\/p>\n

o\u00a0\u00a0 Deleted \u201c+\u201d in front of code 61864<\/p>\n

\u00b7\u00a0 Source\/Citation Section:<\/p>\n

Added 3 citations<\/p>\n

 <\/td>\n

12\/1\/2021<\/td>\nCommercial<\/p>\n

Medicare<\/p>\n

Medicaid<\/td>\n

Medical<\/td>\n<\/tr>\n
Tumor Treatment Fields (TTFs) (i.e., Optune Device<\/td>\nUM659POL<\/td>\n\u00b7\u00a0 I., Criteria for Approval:<\/p>\n

o\u00a0\u00a0 Added \u201cCommercial and MassHealth (Confirmed with Commonwealth Care Alliance)\u201d<\/p>\n

o\u00a0\u00a0 A., 2.:\u00a0 added \u201cTemozolomide\u201d<\/p>\n

\u00b7\u00a0 II., (New)<\/p>\n

o\u00a0\u00a0 Added II., Criteria for Approval for Medicare \u2013 Follow link below:<\/p>\n

https:\/\/www.cms.gov\/medicare-coverage-database\/details\/lcd-details.aspx?LCDId=34823<\/a><\/p>\n

o\u00a0\u00a0 Former II. changed to III<\/p>\n

o\u00a0\u00a0 Former III. changed to IV.<\/p>\n

\u00b7 IV., What is Not Covered<\/p>\n

Added letters I., J., and K.<\/p>\n

\u00b7 V., HCPC Code (Former IV.)<\/p>\n

Code A4555 is removed.<\/p>\n

\u00b7\u00a0 Source\/Citation Section:<\/p>\n

Confirmed, with 4 new citations added<\/p>\n

 <\/td>\n

12\/1\/2021<\/td>\nCommercial<\/p>\n

Medicare<\/p>\n

 <\/td>\n

Medical<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

 <\/p>\n","protected":false},"excerpt":{"rendered":"

Health New England reviews clinical policies and updates accordingly. These policies reside at healthnewengland.org\/Providers\/Resources. Once on the Resources page, click on Behavioral Health\/Medical Policies to learn more. *Please note, new\/revised policies may not appear until closer to the effective date.   Medical Policy\u00a0Title   Policy\u00a0Number   Description of Change   Effective\u00a0Date   LOB\u00a0Affected   Policy […]<\/p>\n","protected":false},"author":1,"featured_media":6852,"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-6851","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\/2021\/09\/male-glasses-work-computer.jpg?fit=2121%2C1414","jetpack_sharing_enabled":true,"jetpack_shortlink":"https:\/\/wp.me\/p6ZZHB-1Mv","_links":{"self":[{"href":"http:\/\/hnetalk.com\/provider\/wp-json\/wp\/v2\/posts\/6851","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=6851"}],"version-history":[{"count":4,"href":"http:\/\/hnetalk.com\/provider\/wp-json\/wp\/v2\/posts\/6851\/revisions"}],"predecessor-version":[{"id":6856,"href":"http:\/\/hnetalk.com\/provider\/wp-json\/wp\/v2\/posts\/6851\/revisions\/6856"}],"wp:featuredmedia":[{"embeddable":true,"href":"http:\/\/hnetalk.com\/provider\/wp-json\/wp\/v2\/media\/6852"}],"wp:attachment":[{"href":"http:\/\/hnetalk.com\/provider\/wp-json\/wp\/v2\/media?parent=6851"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"http:\/\/hnetalk.com\/provider\/wp-json\/wp\/v2\/categories?post=6851"},{"taxonomy":"post_tag","embeddable":true,"href":"http:\/\/hnetalk.com\/provider\/wp-json\/wp\/v2\/tags?post=6851"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}