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Network Matters
News and Information for the
Harvard Pilgrim Health Care Network

July 2017

Updates to Medical Policies


Harvard Pilgrim regularly reviews our medical policies and criteria and makes updates based on the current clinical literature and best practices. Based on this ongoing review, Harvard Pilgrim is making the following updates, effective immediately.

Alcohol Ablation for Hypertrophic Obstructive Cardiomyopathy (HOCM)

Harvard Pilgrim has updated our Alcohol Ablation for Hypertrophic Obstructive Cardiomyopathy (HOCM) Medical Policy to include additional information about the four classes of heart failure and to outline the criteria that must now be met in order for alcohol ablation to be covered for HOCM. Alcohol ablation is considered medically necessary for the treatment of HOCM when the patient displays all of the following criteria:

  • Severe heart failure symptoms as reflection by the New York Heart Association class III or IV or other symptoms upon exertion (such as syncope or near syncope), non-responsive to drug therapy
  • Left ventricular outflow tract gradient greater than or equal to 50 mm Hg at rest or with physiological provocation, including but not limited to exercise or medication administration
  • Absence of coronary artery disease that would impede performance of the procedure

Additionally, the following code has been added to the policy as eligible:

    93583 – Percutaneous transcatheter septal reduction therapy (e.g., alcohol septal ablation) including temporary pacemaker insertion when performed
Prior authorization is not required.

Chest Wall Deformities Reconstructive Procedures
 
Harvard Pilgrim has also updated our commercial and StrideSM (HMO) Medicare Advantage Chest Wall Deformities Reconstructive Procedures Medical Review Criteria. Previously titled Cosmetic and Reconstructive Chest Surgery Medical Review Criteria, these policies were renamed to more accurately reflect the nature of the procedures. In addition, some clarifications were added to the criteria for coverage, as well as the following coverage exclusions:

  • Charges for items or services (e.g., drugs, biologicals) directly related to a non-covered cosmetic procedure
  • Cosmetic procedures to reshape body parts in order to improve the member’s appearance or self-esteem when no physical functional impairment exists
Gynecomastia
Harvard Pilgrim has also updated our commercial and StrideSM (HMO) Medicare Advantage Gynecomastia Medical Review Criteria. Harvard Pilgrim will now require colored photographs to confirm that the patient has Klinefelter’s syndrome; documentation that confirms all of the following is required:

  • Patient is male and 18 years of age or older (as opposed to the previous cutoff of 17 years of age)
    Physical examination, mammogram, or tissue pathology confirms that breast tissue is glandular, not fatty tissue
  • Patient experiences tenderness or pain in breast tissue
    Grade III or IV gynecomastia (unilateral or bilateral) persists more than 1 year or persists after 6 months of unsuccessful medical treatment of pathological gynecomastia
  • History excludes alcohol abuse and use of medications or other substances (e.g., hormones, steroids, supplements, herbal products) from contributing to gynecomastia
  • Preoperative photographs are provided
In addition, the following code has been added to the StrideSM (HMO) Medicare Advantage Gynecomastia Medical Review Criteria as eligible for coverage with prior authorization:
    19300 – Mastectomy for gynecomastia

For more information, and for complete coverage criteria and exclusions, please refer to the applicable updated policy:

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