{"id":9035,"date":"2026-10-29T17:02:24","date_gmt":"2026-10-29T17:02:24","guid":{"rendered":"https:\/\/hnetalk.com\/provider\/?p=9035"},"modified":"2026-10-30T19:15:39","modified_gmt":"2026-10-30T19:15:39","slug":"medical-policy-updates-nov-26","status":"publish","type":"post","link":"https:\/\/hnetalk.com\/provider\/medical-policy-updates-nov-26\/","title":{"rendered":"Medical Policy Updates (November 2026)"},"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. To find policies noted below, please visit healthnewengland.org\/Providers\/Resources<\/strong><\/a>.<\/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
Medical Policies<\/strong><\/td>\nEffective Date<\/strong><\/td>\nNotes<\/strong><\/td>\n<\/tr>\n
Medical Policy Updates:<\/strong><\/p>\n

All Lines of Business<\/em><\/strong><\/td>\n

February 2027<\/td>\nBariatric Surgery<\/strong><\/p>\n
    \n
  • Endoscopic Sleeve Gastrectomy (ESG) criteria added.<\/li>\n
  • CPT code 43889 is now covered with prior authorization for all lines of business.<\/li>\n
  • For Medicare, HNE adopted the InterQual criteria:\n
      \n
    • Procedures, Bariatric Surgery for Treatment of Co-Morbid Conditions Related to Morbid Obesity NCD, Bariatric Surgery.<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n

       <\/p>\n

      Corneal Remodeling for Refractive Errors and Corneal Grafting and Transplantation<\/strong><\/p>\n

        \n
      • Added criteria for corneal graft and amniotic membrane transplantation, corneal stromal lenticule transplantation, limbal stem cell transplantation, and sural nerve grafting for ocular indications across all lines of business.<\/li>\n
      • Updated CPT\/HCPCS and ICD-10 coding guidance and references.<\/li>\n<\/ul>\n

         <\/p>\n

        Lutetium Therapeutic Radiopharmaceuticals <\/strong><\/p>\n

          \n
        • Updated Lutathera criterion I(4) to clarify Ki-67 requirements for well-differentiated G1\/G2 (<20%) and G3 (<55%) neuroendocrine tumors.<\/li>\n
        • Definitions were also revised.<\/li>\n<\/ul>\n

           <\/p>\n

          Lymphedema – Surgical Treatment <\/strong><\/p>\n

            \n
          • No changes were made to the criteria.<\/li>\n
          • CPT 15847 was removed as it is not applicable to this medical policy.<\/li>\n<\/ul>\n

             <\/p>\n

            Speech Language Pathology (SLP) Services <\/strong><\/p>\n

              \n
            • Minor criteria changes<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n
Medical Policy Updates: Medicare LOB Only<\/em><\/strong><\/td>\nFebruary 2027<\/td>\nFor the Medicare line of business, HNE has adopted the InterQual criteria for the following:<\/p>\n

Achalasia and Gastroesophageal Reflux Disease (GERD)<\/strong><\/p>\n

    \n
  • Procedures, Select Minimally Invasive GERD Procedures Wellpoint, Transoral Incisionless Fundoplication (TIF)<\/li>\n<\/ul>\n

     <\/p>\n

    Cochlear Implants\/BAHA\/ABI\/Bone – Conduction Hearing Aid<\/strong><\/p>\n

      \n
    • Cochlear Implantation: Procedures, Cochlear Implant NCD, Cochlear Implantation<\/li>\n
    • Cochlear Implantation \u2013 Clinical Trial: Procedures, Cochlear Implant NCD, Cochlear Implantation, Clinical Trial<\/li>\n
    • Cochlear Implantation \u2013 IDE: Procedures, Cochlear Implant NCD, Cochlear Implantation IDE<\/li>\n<\/ul>\n

       <\/p>\n

      Percutaneous Left Atrial Appendage Closure<\/strong><\/p>\n

        \n
      • Procedures, Percutaneous Left Atrial Appendage Closure (LAAC) NCD, Left Atrial Appendage Closure (LAAC) (CED)<\/li>\n
      • Procedures, Percutaneous Left Atrial Appendage Closure (LAAC) NCD, Left Atrial Appendage Closure (LAAC) Clinical Trial<\/li>\n<\/ul>\n

         <\/p>\n

        Percutaneous Neuroablation<\/strong><\/p>\n

          \n
        • Medicare coverage of select pain management procedures, including facet joint interventions, neuroablation, and BVN thermal destruction for Vertebrogenic lower back pain<\/li>\n
        • Supporting references have also been updated.<\/li>\n<\/ul>\n

           <\/p>\n

          Transcatheter Mitral Valve Repair<\/strong><\/p>\n

            \n
          • Procedures, Transcatheter Edge-to-Edge Repair (TEER) for Mitral Valve Regurgitation NCD, Transcatheter Edge-to-Edge Repair (TEER) CED Study<\/li>\n
          • Procedures, Transcatheter Edge-to-Edge Repair (TEER) for Mitral Valve Regurgitation NCD, Transcatheter Edge-to-Edge Repair (TEER) Clinical Trial<\/li>\n<\/ul>\n

             <\/p>\n

            Transplants<\/strong><\/p>\n

              \n
            • Updated the Medicare line of business to adopt available Medicare InterQual criteria.<\/li>\n
            • Revised the Policy Guidelines and Definitions section.<\/li>\n<\/ul>\n

               <\/p>\n

              Treatment for Varicose Veins and Venous Insufficiency <\/strong><\/p>\n

                \n
              • Procedures, Varicose Veins of the Lower Extremity, Treatment of Wellpoint, Compression Sclerotherapy or Microphlebectomy<\/li>\n
              • Procedures, Varicose Veins of the Lower Extremity, Treatment of Wellpoint, Ligation +\/- Stripping<\/li>\n
              • Procedures, Varicose Veins of the Lower Extremity, Treatment of Wellpoint, Non-thermal non-tumescent (NTNT) Polidocanol Microfoam (PEM)<\/li>\n<\/ul>\n

                 <\/p>\n

                Ventricular Assist Devices<\/strong><\/p>\n

                  \n
                • Procedures, Ventricular Assist Devices NCD, Ventricular Assist Device<\/li>\n<\/ul>\n<\/td>\n<\/tr>\n
Medical Policy Updates:<\/strong><\/p>\n

Commercial and Medicare LOB Only<\/em><\/strong><\/p>\n

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

February 2027<\/td>\nHome Health Care Services<\/strong> (for Commercial and Medicare Advantage)<\/p>\n

The following criteria were added:<\/p>\n