{"id":8783,"date":"2025-10-06T13:54:45","date_gmt":"2025-10-06T13:54:45","guid":{"rendered":"https:\/\/hnetalk.com\/provider\/?p=8783"},"modified":"2025-10-06T13:54:45","modified_gmt":"2025-10-06T13:54:45","slug":"medical-policy-updates-october-2025","status":"publish","type":"post","link":"http:\/\/hnetalk.com\/provider\/medical-policy-updates-october-2025\/","title":{"rendered":"Medical Policy Updates (October 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.<\/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\n\n\n\n\n\n\n\n\n\n
Medical Policy Updates<\/span><\/b>\u00a0<\/span><\/td>\n\u00a0Effective Date<\/span><\/b>\u00a0<\/span><\/td>\nNotes<\/span><\/b>\u00a0<\/span><\/td>\n<\/tr>\n
Lipodystrophy Syndrome \u2013 HIV Associated<\/span><\/b>\u00a0<\/span><\/td>\n10\/1\/2025<\/span>\u00a0<\/span><\/td>\n\n
    \n
  • Annual review.\u00a0<\/span>\u00a0<\/span><\/li>\n<\/ul>\n
      \n
    • No changes.\u00a0<\/span>\u00a0<\/span><\/li>\n<\/ul>\n<\/td>\n<\/tr>\n
Breast Surgery<\/span><\/b>\u00a0<\/span><\/p>\n

\u00a0<\/span><\/td>\n

\u00a010\/1\/2025<\/span>\u00a0<\/span><\/p>\n

\u00a0<\/span><\/td>\n

\n
    \n
  • Updated with the following changes:<\/span>\u00a0<\/span><\/li>\n<\/ul>\n
      \n
    • \n
        \n
      • Removed Reconstructive Breast Surgery Interqual criteria from the Medicare line of business section.<\/span>\u00a0<\/span><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n
          \n
        • \n
            \n
          • Added C50.A0-C50.A2, Z42.1 to the list of diagnosis codes for breast cancer.\u00a0<\/span>\u00a0<\/span><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n
Cochlear Implants, BAHA (Bone-Anchored Hearing Aid), ABI (Auditory Brainstem Implant), ABI (Auditory Brainstem Implant), Bone-Conduction Hearing Aid<\/span><\/b>\u00a0<\/span><\/td>\n\u00a010\/1\/2025<\/span>\u00a0<\/span><\/td>\n\n
    \n
  • Annual review.<\/span>\u00a0<\/span><\/li>\n<\/ul>\n
      \n
    • Bone-Conduction Hearing Aid Semi-implantable and fully implantable middle ear hearing devices are added to the EXPERIMENTAL and INVESTIGATIONAL list.<\/span>\u00a0<\/span><\/li>\n<\/ul>\n<\/td>\n<\/tr>\n
Home Health Care Services<\/span><\/b> (Commercial and Medicare)<\/span>\u00a0<\/span><\/td>\n10\/1\/2025<\/span>\u00a0<\/span><\/td>\n\n
    \n
  • Annual review.\u00a0<\/span>\u00a0<\/span><\/li>\n<\/ul>\n
      \n
    • No changes to criteria.\u00a0<\/span>\u00a0<\/span><\/li>\n<\/ul>\n<\/td>\n<\/tr>\n
Achalasia and Gastroesophageal Reflux Disease (GERD) – Minimally Invasive Procedures<\/span><\/b>\u00a0<\/span><\/p>\n

\u00a0<\/span><\/td>\n

10\/1\/2025<\/span>\u00a0<\/span><\/td>\n\n
    \n
  • Annual review.<\/span>\u00a0<\/span><\/li>\n<\/ul>\n
      \n
    • Minor changes POEM and GPOEM changed not medically necessary vs. experimental\/investigational when medical necessity criteria is not met.\u00a0<\/span>\u00a0<\/span><\/li>\n<\/ul>\n<\/td>\n<\/tr>\n
Non-Emergent Transportation<\/span><\/b>\u00a0<\/span><\/p>\n

\u00a0<\/span><\/td>\n

\u00a010\/1\/2025<\/span>\u00a0<\/span><\/td>\n\n
    \n
  • Annual review.\u00a0<\/span>\u00a0<\/span><\/li>\n<\/ul>\n
      \n
    • No changes to criteria.\u00a0<\/span>\u00a0<\/span><\/li>\n<\/ul>\n<\/td>\n<\/tr>\n
Leadless Cardiac Pacemaker<\/span><\/b>\u00a0<\/span><\/p>\n

\u00a0<\/span><\/td>\n

\u00a010\/1\/2025<\/span>\u00a0<\/span><\/td>\n\n
    \n
  • New Policy.\u00a0<\/span>\u00a0<\/span><\/li>\n<\/ul>\n
      \n
    • Certain leadless cardiac pacemakers moved from experimental\/investigational to covered for the commercial and Medicare lines of business. (Have been covered by Medicare under a National Coverage Determination, NCD).<\/span>\u00a0<\/span><\/li>\n<\/ul>\n
        \n
      • No prior authorization required.<\/span>\u00a0<\/span><\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\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-8783","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-2hF","_links":{"self":[{"href":"http:\/\/hnetalk.com\/provider\/wp-json\/wp\/v2\/posts\/8783","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=8783"}],"version-history":[{"count":2,"href":"http:\/\/hnetalk.com\/provider\/wp-json\/wp\/v2\/posts\/8783\/revisions"}],"predecessor-version":[{"id":8785,"href":"http:\/\/hnetalk.com\/provider\/wp-json\/wp\/v2\/posts\/8783\/revisions\/8785"}],"wp:attachment":[{"href":"http:\/\/hnetalk.com\/provider\/wp-json\/wp\/v2\/media?parent=8783"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"http:\/\/hnetalk.com\/provider\/wp-json\/wp\/v2\/categories?post=8783"},{"taxonomy":"post_tag","embeddable":true,"href":"http:\/\/hnetalk.com\/provider\/wp-json\/wp\/v2\/tags?post=8783"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}