Harvard Pilgrim Health Care Home
  HPHConnect
 
  Learn more.
  Sign up for HPHConnect.
Medical Management
E-Transactions
HPHConnect
Pharmacy
For Your Patient
News Center
Network Matters
Newsletter Archives
Newsletter Registration
Newsroom
Office Support
Products
Provider Manual
Medicare Advantage
Research & Teaching
Resources & Links
 
Print    Text Size

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.

Email this article to a colleague   


Network Matters Archives

Download printer-friendly version

HPHCURRENT EVENTS

Genetic Testing Prior Authorization for Commercial Members

Maximum Dosages for Medical Drugs

HPI to Administer Boston Medical Center Plan

Update for Dartmouth-Hitchcock and Alice Peck Medical Benefit Plans

Coverage for Out-of-Area Dependents

CLINICIAN CORNER

Prior Authorization Policy Updates

Substance Abuse and Depression in Primary Care

OFFICE ASSISTANT

2018 Fee Schedule Updates

Payment Policy Updates: Billing for Multiple Dates of Service

PUBLICATION INFORMATION

Eric H. Schultz,
President and Chief Executive Officer

Robert Farias,
Senior Vice President, Network Strategy

Annmarie Dadoly,
Editor

Joseph O'Riordan,
Writer

Kristin Edmonston,
Production Coordinator