{"id":8759,"date":"2025-09-04T18:05:56","date_gmt":"2025-09-04T18:05:56","guid":{"rendered":"https:\/\/hnetalk.com\/provider\/?p=8759"},"modified":"2025-09-04T18:05:56","modified_gmt":"2025-09-04T18:05:56","slug":"medical-policy-updates-september-2025","status":"publish","type":"post","link":"http:\/\/hnetalk.com\/provider\/medical-policy-updates-september-2025\/","title":{"rendered":"Medical Policy Updates (September 2025)"},"content":{"rendered":"

Please read the following update related to various Health New England programs and changes that may have an impact on your patients and\/or your practice.<\/span><\/p>\n

If you have any questions about the information in this notice, please contact Health New England Provider Experience at (800) 842-4464, extension 5000. A representative is available Monday through Friday between the hours of 8:00 a.m. and 5:00 p.m.<\/p>\n

 <\/p>\n\n\n\n\n\n\n\n\n\n\n
Medical Policy –\u00a0 Annual Review<\/span><\/i><\/b><\/td>\nEffective Date<\/span><\/i><\/b>\u00a0<\/span><\/td>\nSummary of Changes<\/span><\/i><\/b>\u00a0<\/span><\/td>\n<\/tr>\n
Home Health Care Services Medicaid<\/td>\n\u00a011\/1\/2025<\/span><\/b>\u00a0<\/span><\/td>\n\n
    \n
  • Updated Physical and Occupational Therapy criteria to follow the outpatient therapy guidelines. (This aligns with the MassHealth Guidelines for Home Health.)<\/li>\n
  • In \u201cLimitations and Exclusions,\u201d removed paragraph regarding Maintenance Home Health Care Services as this is addressed in the Home Health Aid (HHA) only criteria.<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n
Clinical Trial<\/td>\n10\/1\/2025<\/span><\/b>\u00a0<\/span><\/td>\n\n
    \n
  • In \u201cWhat is Not Covered,\u201d clarified number 8, costs of services.<\/li>\n
  • Updated Definitions (HUD and HDE) and References.<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n
Artificial Cervical Intervertebral Disc <\/span>\u00a0<\/span><\/td>\n10\/1\/2025<\/span><\/b>\u00a0<\/span><\/td>\n\n
    \n
  • Added InterQual criteria for Cervical Artificial Disc Removal and Replacement. PA not required for the procedures.<\/li>\n
  • Added CPT codes 22861 and 22864 to the coding table.<\/li>\n
  • PA not required.<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n
Bone Grafts and Stabilization Devices for Spinal Defects<\/td>\n10\/1\/2025<\/span><\/b>\u00a0<\/span><\/td>\n\n
    \n
  • Minor Criteria Changes<\/li>\n
  • Experimental and Investigational bone graft substitutes list reviewed and updated.<\/li>\n
  • Experimental and Investigational Interlaminar Stabilization Devices list reviewed and updated.<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n
Medical Necessity and Experimental and Investigational<\/td>\n10\/1\/2025<\/span><\/b>\u00a0<\/span><\/td>\n\n
    \n
  • Experimental and Investigational definition revised.<\/li>\n
  • Under \u201cPolicy Guidelines,\u201d added InterQual \u201cCP: Procedures\u201d Criteria as IA2.<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n
Abdominal Panniculectomy and Excision of Excessive Skin and Subcutaneous Tissue<\/td>\n10\/1\/2025<\/span><\/b>\u00a0<\/span><\/td>\n\n
    \n
  • Minimal changes to criteria<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n
Azedra<\/td>\n<\/td>\n\n
    \n
  • No changes to criteria<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

     <\/p>\n\n\n\n\n\n
    Medical Policy –\u00a0 New<\/span><\/i><\/b><\/td>\nEffective Date<\/span><\/i><\/b>\u00a0<\/span><\/td>\nSummary of Changes<\/span><\/i><\/b>\u00a0<\/span><\/td>\n<\/tr>\n
    Hospice and Palliative Care<\/td>\n\u00a011\/1\/2025<\/span><\/b>\u00a0<\/span><\/td>\n\n
      \n
    • Services have required PA, but did not have medical necessity criteria in the past.<\/li>\n
    • Applies to Commercial and MassHealth lines of business (Medicare Advantage is covered by Medicare fee-for-service and not Health New England).<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n
    Long-Term Acute Care (LTAC)<\/td>\n10\/1\/2025<\/span><\/b>\u00a0<\/span><\/td>\n\n
      \n
    • Documents current process.<\/li>\n
    • Applies to all lines of business.<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

       <\/p>\n\n\n\n\n
      Medical Policy –\u00a0 Quarterly<\/span><\/i><\/b><\/td>\nEffective Date<\/span><\/i><\/b>\u00a0<\/span><\/td>\nSummary of Changes<\/span><\/i><\/b>\u00a0<\/span><\/td>\n<\/tr>\n
      Skin and Soft Tissue Substitutes<\/td>\n\u00a07\/1\/2025<\/span><\/b>\u00a0<\/span><\/td>\n\n
        \n
      • Q4368, Q4369, Q4370, Q4371, Q4372, Q4373, Q4375, Q4376, Q4377, Q4378, Q4379, Q4380, Q4382 added to Experimental\/Investigational list, effective 7\/1\/2025.<\/li>\n
      • Q4132, Q4137, Q4154, Q4168 removed from the Experimental\/Investigational list.<\/li>\n
      • Added ophthalmic conditions to covered conditions.<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

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

        Please read the following update related to various Health New England programs and changes that may have an impact on your patients and\/or your practice. If you have any questions about the information in this notice, please contact Health New England Provider Experience at (800) 842-4464, extension 5000. A representative is available Monday through Friday […]<\/p>\n","protected":false},"author":11,"featured_media":0,"comment_status":"closed","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-8759","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-2hh","_links":{"self":[{"href":"http:\/\/hnetalk.com\/provider\/wp-json\/wp\/v2\/posts\/8759","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\/11"}],"replies":[{"embeddable":true,"href":"http:\/\/hnetalk.com\/provider\/wp-json\/wp\/v2\/comments?post=8759"}],"version-history":[{"count":5,"href":"http:\/\/hnetalk.com\/provider\/wp-json\/wp\/v2\/posts\/8759\/revisions"}],"predecessor-version":[{"id":8765,"href":"http:\/\/hnetalk.com\/provider\/wp-json\/wp\/v2\/posts\/8759\/revisions\/8765"}],"wp:attachment":[{"href":"http:\/\/hnetalk.com\/provider\/wp-json\/wp\/v2\/media?parent=8759"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"http:\/\/hnetalk.com\/provider\/wp-json\/wp\/v2\/categories?post=8759"},{"taxonomy":"post_tag","embeddable":true,"href":"http:\/\/hnetalk.com\/provider\/wp-json\/wp\/v2\/tags?post=8759"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}