Harvard Pilgrim is introducing several new policies and updating existing ones for StrideSM(HMO) Medicare Advantage members. Changes include requiring prior authorization for sleep studies; select hip, knee, and shoulder surgeries; and genetic/genomic and molecular testing, as well as updates to several existing policies. All of the following changes are effective for dates of service beginning Jan. 1, 2018 for Stride members.
Sleep studies authorization
National Imaging Associates, Inc. (NIA) will provide utilization management for sleep diagnostic services, including attended and home sleep studies, for Stride (HMO) Medicare Advantage members with a risk of sleep disorders. This prior authorization program was introduced for members of our commercial products (HMO, POS, PPO, and Access America) in September and is being expanded to include Medicare Advantage members.
The following CPT codes will be eligible for coverage with prior authorization: 95800, 95801, 95805, 95806, 95807, 95808, 95810, 95811, G0398, G0399, G0400.
To request prior authorization for sleep studies, ordering providers should contact NIA in one of the following ways:
Providers may begin making prior authorization requests for sleep studies through NIA on Dec. 26, 2017. When requesting prior authorization, please be prepared to provide the information noted in the Sleep Assessment Records Checklist. For more information, please refer to our Stride (HMO) Medicare Advantage Sleep Studies Authorization Policy and NIA’s sleep studies criteria.
Select hip, knee, and shoulder surgeries
Harvard Pilgrim is also requiring prior authorization through NIA for select hip, knee, and shoulder surgeries. This change takes effect for dates of service beginning Jan. 1, 2018 for Stride members and Dec. 11, 2017 for commercial members enrolled in our HMO, PPO, and POS products. For details, please see the companion article in this month’s issue of the newsletter.
Genetic/genomic and molecular diagnostic testing
In addition, Harvard Pilgrim is requiring prior authorization through AIM Specialty Health for genetic/genomic and molecular testing, including:
- Genetic testing for hereditary cardiac disease
- Genetic testing for hereditary cancer susceptibility
- Genetic testing for single-gene and multifactorial conditions
- Pharmacogenetic and thrombophilia genetic testing
- Reproductive carrier screening and prenatal diagnosis
- Somatic tumor testing
- Whole genome sequencing
The ordering clinician is responsible for obtaining prior authorization through AIM Specialty Health. Any genetic/genomic and molecular tests performed on or beyond Jan. 1, 2018 will not be reimbursed if a prior authorization was not obtained. Therefore, to ensure that they are eligible for reimbursement, providers rendering these services should verify that the necessary prior authorization has been obtained prior to performing the test.
Ordering providers should request prior authorization in one of the following ways:
Refer to AIM’s website, www.aimspecialtyhealth.com, for AIM registration instructions.
Providers may begin making prior authorization requests for genetic/genomic and molecular testing beginning Dec. 18, 2017. For more information, please refer to the following:
AIM Specialty Health is also developing a website for Harvard Pilgrim providers that will include additional resources. Please refer to future issues of Network Matters for more information about the microsite and provider webinars.
The Cholecystectomy Surgery Medical Review Criteria is being updated for the coming year, as well. Harvard Pilgrim will require prior authorization for the following CPT codes: 47564, 47579, and 47610. For details, please refer to the Cholecystectomy article in this issue.
Harvard Pilgrim is updating our Stride (HMO) Medicare Advantage medical review criteria for endoscopic sinus procedures to allow coverage for the following CPT codes with prior authorization: 31231, 31233, 31235, 31237, 31238, 31239, 31240, 31287, 31290, 31291, 31292, 31297, 30130, and 30140. For more information, please refer to Harvard Pilgrim’s updated Stride (HMO) Medicare Advantage Sinus Surgeries Medical Review Criteria .
Harvard Pilgrim is also including several updates to our medical review criteria for dermabrasion. Changes to the policy include: removal of numerous ICD-10 codes that are inconsistent with the policy and the addition of exclusions to coverage. Exclusions to coverage include: microdermabrasion, tattoo removal, and dermabrasion for uneven pigmentation. For more information, please refer to Harvard Pilgrim’s updated Stride (HMO) Medicare Advantage Dermabrasion Medical Review Criteria.
Durable Medical Equipment
We are also updating our Stride (HMO) Medicare Advantage Durable Medical Equipment (DME) Medical Review Criteria to require prior authorization for any single DME item with an allowed payable amount of $500 or more. The previous threshold was $750. For more information, please refer to the updated Stride (HMO) Medicare Advantage DME Medical Review Criteria and the DME Prior Authorization Request Form.
Transgender health services
Harvard Pilgrim is updating our medical review criteria for transgender health services to correct coding and add exclusions to coverage. Exclusions to coverage include: abdominoplasty; chin augmentation (e.g., genioplasty, mentoplasty); dermabrasion; chemical peels; gender reversal surgery; implantations (e.g., calf, pectoral, gluteal); otoplasty; panniculectomy; voice modification therapy; and reimbursement for travel expenses. Please refer to Harvard Pilgrim’s updated Stride (HMO) Medicare Advantage Transgender Health Services Medical Review Criteria for more information.
Harvard Pilgrim is updating our medical review criteria for reduction mammoplasty to allow coverage for one additional CPT code: 19300 (mastectomy for gynecomastia). Harvard Pilgrim covers medically necessary reduction mammoplasty, with prior authorization, when all criteria indicated in the Stride (HMO) Medicare Advantage Reduction Mammoplasty Medical Review Criteria are met.
Additional policy updates
Updates are also being made to the following, as announced in previous issues of Network Matters. However, some of these announcements provided a single effective date for both commercial and Medicare Advantage. While any published effective dates were correct for commercial members, the effective dates for Medicare Advantage are Jan. 1, 2018.