{"id":8453,"date":"2023-12-28T16:58:04","date_gmt":"2023-12-28T16:58:04","guid":{"rendered":"http:\/\/hnetalk.com\/provider\/?p=8453"},"modified":"2024-01-09T18:31:29","modified_gmt":"2024-01-09T18:31:29","slug":"clinical-review-criteria-january-2024","status":"publish","type":"post","link":"http:\/\/hnetalk.com\/provider\/clinical-review-criteria-january-2024\/","title":{"rendered":"Clinical Review Criteria"},"content":{"rendered":"<p>Health New England reviews clinical policies and updates accordingly. These policies reside at <a href=\"https:\/\/healthnewengland.org\/Providers\/Resources\" target=\"_blank\" rel=\"noopener\"><strong>healthnewengland.org\/Providers\/Resources<\/strong><\/a>. Once on the Resources page, click on <strong><em>Behavioral Health\/Medical Policies <\/em><\/strong>to learn more.<\/p>\n<p><strong>Endothelial Keratoplasty<\/strong><\/p>\n<ul>\n<li>Retired effective 1\/1\/2024<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<p><strong>Non-Covered, Experimental and Investigational Services<\/strong><\/p>\n<ul>\n<li>Retired effective 1\/1\/2024 &#8211; see Medical Necessity<\/li>\n<\/ul>\n<p><strong>\u00a0<\/strong><\/p>\n<p><strong>Lipodystrophy Syndrome &#8211; HIV associated <\/strong><\/p>\n<ul>\n<li>Effective 3\/1\/2024<\/li>\n<li>Name changed from Treatment of Lipodystrophy Syndrome (LDS)<\/li>\n<li>No significant change to criteria but codes added to align with MassHealth<\/li>\n<\/ul>\n<p><strong>\u00a0<\/strong><\/p>\n<p><strong>Speech Therapy <\/strong><\/p>\n<ul>\n<li>Effective 3\/1\/2024<\/li>\n<li>Clarified IV D 1 under policy guidelines and definitions<\/li>\n<li>Added links to Medicare and MassHealth criteria<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<p><strong>Percutaneous Left Atrial Appendage Closure <\/strong><\/p>\n<ul>\n<li>Effective 2\/1\/2024<\/li>\n<li>No changes to criteria with the exception of adding Medicare LCD<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<p><strong>Tumor Treatment Fields<\/strong><\/p>\n<ul>\n<li>Effective 2\/1\/2024<\/li>\n<li>No significant criteria changes<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<p><strong>Hydrogen Breath Testing<\/strong><\/p>\n<ul>\n<li>Effective 2\/1\/2024<\/li>\n<li>Added NCD link<\/li>\n<li>No significant changes<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<p><strong>Dental Anesthesia<\/strong><\/p>\n<ul>\n<li>Effective 1\/1\/2024<\/li>\n<li>No changes to policy, updated references for Medicare<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<p><strong>Medical Necessity<\/strong><\/p>\n<ul>\n<li>Update effective 1\/1\/2024<\/li>\n<li>Not Medically Necessary section added; this was previously on the Non-Covered Services Policy and was added with no change to criteria.<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<p><strong>Prostate Procedures (BPH and Prostate Cancer)<\/strong><\/p>\n<ul>\n<li>New Policy effective 3\/1\/2024<\/li>\n<li>The following policies will be retired and are incorporated into this policy effective 3\/1\/2024:\n<ul>\n<li>Water Vapor Thermal Therapy<\/li>\n<li>Transurethral Water Jet Ablation<\/li>\n<li>High Intensity Focused Ultrasound (HIFU) for the treatment of Prostate Cancer<\/li>\n<\/ul>\n<\/li>\n<li>PA added to the following CPT codes 52441, 52442, 53850, 55874<\/li>\n<li>CPT 53852 added to experimental\/investigational list<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<p><strong>Deep Brain and Cortical Stimulation<\/strong><\/p>\n<ul>\n<li>Effective 1\/1\/2024<\/li>\n<li>Name changed from Deep Brain Stimulator<\/li>\n<li>Added codes that are effective 1\/1\/2024 for Responsive Cortical Stimulation<\/li>\n<li>Added NCD for Medicare line of business<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<p><strong>Spinal Cord and Dorsal Root Ganglion Stimulation<\/strong><\/p>\n<ul>\n<li>Effective 1\/1\/2024<\/li>\n<li>Name changed from Spinal Cord Stimulators<\/li>\n<li>No significant change to criteria<\/li>\n<li>Removed cardiac pacemakers and defibrillators from Contraindications section<\/li>\n<li>Updated Experimental\/Investigational and Contraindications section<\/li>\n<li>Updated codes for 2024 CPT changes<\/li>\n<li>Added 63688 (for revision) to codes requiring PA<\/li>\n<li>Added 64553 (for trial) Code already requires PA on other policies<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<p><strong>Achalasia and Gastroesophageal Reflux Disease (GERD) &#8211; Minimally Invasive Procedures<\/strong><\/p>\n<ul>\n<li>Effective 2\/1\/2024<\/li>\n<li>Name changed from Peroral Endoscopic Myotomy (POEM)<\/li>\n<li>Criteria updated to be less restrictive<\/li>\n<li>Added procedures for GERD that are Experimental &amp;Investigational to the policy<\/li>\n<li>Transplants<\/li>\n<li>Ventricular Assist Devices (VAD) moved to separate policy<\/li>\n<li>Updated NCDs and coding table<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<p><strong>Transplants<\/strong><\/p>\n<ul>\n<li>Ventricular Assist Devices (VAD) moved to separate policy<\/li>\n<li>Updated NCDs and coding table<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<p><strong>Ventricular Assist Devices<\/strong><\/p>\n<ul>\n<li>Effective 2\/1\/2024<\/li>\n<li>Was previously included in Transplant policy<\/li>\n<li>Criteria clarified, no significant change<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<p><strong>Peripherally Implanted Nerve Stimulation (PNS)\/Peripheral Subcutaneous Field Stimulation (PSFS)<\/strong><\/p>\n<ul>\n<li>Effective 1\/1\/2024 (coding changes)<\/li>\n<li>Criteria clarified with no significant change<\/li>\n<li>Codes updated and added due to 2024 CPT changes<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<p><strong>Infertility Treatment<\/strong><\/p>\n<ul>\n<li>Effective 2\/1\/2024<\/li>\n<li>Moved to new template with no significant change<\/li>\n<li>Clarified biological male and biological female<\/li>\n<li>Therapeutic Contact Lens &#8211; Medical Policy<\/li>\n<li>Effective 2\/1\/2024<\/li>\n<li>Policy moved to new template and rewritten with no significant change to criteria<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<p><strong>Azedra (iobenguane I-131)<\/strong><\/p>\n<ul>\n<li>Effective 2\/1\/2024<\/li>\n<li>Moved to new template with no significant change<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<p><strong>Transanal Endoscopic Microsurgery<\/strong><\/p>\n<ul>\n<li>Effective 2\/1\/2024<\/li>\n<li>Moved to new template with no significant changes<\/li>\n<li>Artificial Cervical Disk<\/li>\n<li>Effective 2\/1\/2024<\/li>\n<li>Moved to new template with no significant changes<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<p><strong>Abdominal Panniculectomy and Excision of Excessive Skin and Subcutaneous Tissue<\/strong><\/p>\n<ul>\n<li>Effective 3\/1\/2024<\/li>\n<li>Moved to new template<\/li>\n<li>For Commercial, will use InterQual for panniculectomy<\/li>\n<li>For Medicare Advantage, will use local coverage determination (LCD) for panniculectomy<\/li>\n<li>For MassHealth, will use MassHealth guidelines for panniculectomy and removal of excessive skin<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<p><strong>Sleep Disordered Breathing Diagnosis and Treatment<\/strong><\/p>\n<ul>\n<li>Effective 3\/1\/2024<\/li>\n<li>The following policies will be retired effective 3\/1\/2023:\n<ul>\n<li>Laser-Assisted Uvulopalatoplasty or Uvulopalatopharyngoplasty<\/li>\n<li>Upper Airway Stimulation Device (UAS)\/Hypoglossal Nerve Stimulation (HGNS) (Inspire)<\/li>\n<\/ul>\n<\/li>\n<li>Minor changes made to Diagnosis of Obstructive Sleep Apnea and Sleep Disorders<\/li>\n<li>Treatment of Obstructive Sleep Apnea (OSA) and Upper Airway Resistance Syndrome (UARS) section added<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<p><span style=\"text-decoration: underline;\"><strong>Behavioral Health Policies<\/strong><\/span><\/p>\n<p><strong>Applied Behavioral Analysis for Autism Spectrum Disorder<\/strong><\/p>\n<ul>\n<li>Effective 2\/1\/2024<\/li>\n<li>Moved to new template with no significant change<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<p>For more information, please do not hesitate to call your Provider Experience Department at (800) 842-4464, extension 5000, or send an email to <a href=\"mailto:providerrelations@hne.com\" target=\"_blank\" rel=\"noopener\">providerrelations@hne.com<\/a>.<\/p>\n","protected":false},"excerpt":{"rendered":"<p>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. Endothelial Keratoplasty Retired effective 1\/1\/2024 &nbsp; Non-Covered, Experimental and Investigational Services Retired effective 1\/1\/2024 &#8211; see Medical Necessity \u00a0 Lipodystrophy Syndrome &#8211; HIV associated Effective 3\/1\/2024 Name changed [&hellip;]<\/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-8453","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-2cl","_links":{"self":[{"href":"http:\/\/hnetalk.com\/provider\/wp-json\/wp\/v2\/posts\/8453","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=8453"}],"version-history":[{"count":6,"href":"http:\/\/hnetalk.com\/provider\/wp-json\/wp\/v2\/posts\/8453\/revisions"}],"predecessor-version":[{"id":8466,"href":"http:\/\/hnetalk.com\/provider\/wp-json\/wp\/v2\/posts\/8453\/revisions\/8466"}],"wp:attachment":[{"href":"http:\/\/hnetalk.com\/provider\/wp-json\/wp\/v2\/media?parent=8453"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"http:\/\/hnetalk.com\/provider\/wp-json\/wp\/v2\/categories?post=8453"},{"taxonomy":"post_tag","embeddable":true,"href":"http:\/\/hnetalk.com\/provider\/wp-json\/wp\/v2\/tags?post=8453"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}