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

January 2018

Prior Authorization Policy Updates

Harvard Pilgrim has made some updates to our commercial prior authorization policies for breast surgeries, cosmetic and reconstructive nasal procedures, and cosmetic and reconstructive eye procedures. The updates regarding breast surgeries will take effect March 1, 2018, while those for cosmetic and reconstructive nasal and eye procedures are effective immediately.

Breast surgeries

Harvard Pilgrim’s updated prior authorization policy for breast surgeries provides clarification regarding reimbursement for reconstruction of the contralateral breast. Harvard Pilgrim covers reconstruction of the contralateral breast when documentation demonstrates that the procedure is necessary for the repair of breast asymmetry caused by mastectomy or medically necessary lumpectomy.
In addition, effective March 1, 2018, Harvard Pilgrim will require prior authorization for the coverage of the following two CPT codes:

  • 19370 – Open periprosthetic capsulotomy, breast
  • 19371 – Periprosthetic capsulectomy, breast
Cosmetic and reconstructive nasal and eye procedures

The updates to Harvard Pilgrim’s prior authorization policy for cosmetic and reconstructive nasal procedures are designed to provide greater clarity around the criteria for coverage. We have also added the following criteria that must be met for excision or shaving of rhinophyma to be reimbursed:

  • Documentation shows evidence of bleeding or infection, and
  • Treatment of bleeding or infection is refractory to medical therapy, and
  • Procedure is reasonably expected to improve physical functional impairment from bleeding or infection

Updates to our prior authorization policy for cosmetic and reconstructive eye procedures are based on American Society of Ophthalmic Plastic and Reconstructive Surgery and local coverage determination guidelines, and include:

  • Modifying the criteria for the photo documentation needed for the coverage of brow ptosis repair, blepharoplasty, and blepharoptosis
  • For blepharoplasty and blepharoptosis, requiring that visual fields meet accepted standards when performed by the Goldmann perimeter or some other standardized perimetry techniques
  • Indicating that the member must experience interference and visual obstruction due to excessive overhanging skin to be covered for blepharoplasty

For complete information, please refer to our updated Breast Surgeries Medical Review Criteria, Cosmetic and Reconstructive Nasal Procedures Medical Review Criteria, and Cosmetic and Reconstructive Eye Procedures Medical Review Criteria.

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