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

March 2016

Clinical Policy and Prior Authorization Updates


Harvard Pilgrim regularly reviews clinical literature, best practices, and our existing clinical policies, and creates new policies and updates existing ones based on this information. The chart below summarizes policy and procedure changes based on this ongoing review, and provides their respective effective dates.

Harvard Pilgrim welcomes your feedback related to the research and development of our medical policies and clinical utilization management guidelines, and encourages you to send your comments and questions to medical_policy_team@harvardpilgrim.org. All other inquires (on claims, referrals, billing practices, etc.) should continue to be directed to our Provider Service Center at 800-708-4414.

    Clinical Policy and Prior Authorization Updates

    Policy/procedure  Description Additional resources

    New code covered — Effective for dates of service beginning Jan.  1, 2016

    Fecal DNA Testing for Colorectal Cancer Screening  

    Clinical evidence and cancer screening guidelines now support the medically necessary use of the Cologuard test for colorectal cancer screening every three years for average risk patients.

    The CPT code 81528 was recently established for colorectal screening, and has been added to our Fecal DNA Testing for Colorectal Cancer Medical Policy.

    New medical policies created — Effective for dates of service beginning April 1, 2016

    Inhaled Nitric Oxide in Newborns  

    Harvard Pilgrim has created a new medical policy that lists the conditions for which inhaled nitric oxide (CPT 93463) is medically appropriate.

    Prior authorization is not required.  

      Vision Surgeries for Refractive Errors This new medical policy outlines the criteria for medical necessity and coverage of certain vision surgeries to correct refractive errors. 

      New prior authorization requirements — Effective for dates of service beginning June 1, 2016

      Coverage is for reasonable, medically necessary, clinically appropriate care that is supported by evidence-based literature. In the cases listed below, prior authorization is required for HMO, POS, and PPO members. The attached policies detail the medical criteria that must be met and documented to obtain authorization.

      Entyvio (vedolizumab)  Coverage of Entyvio (vedolizumab) to treat members 18 and older with moderately to severely active Crohn’s disease and ulcerative colitis. 
      Lemtrada (alemtuzumab)  
      Coverage of Lemtrada
      (alemtuzumab) for the treatment of patients with relapsing multiple sclerosis.  
      Opdivo (nivolumab) 

      Coverage of Opdivo (nivolumab) for the treatment of unresectable or metastatic melanoma, metastatic non-small cell lung cancer, and advanced or metastatic renal cell carcinoma.  

      Keytruda (pembrolizumab)

      Coverage of Keytruda (pembrolizumab) for the treatment of unresectable or metastatic melanoma or metastatic non-small cell lung cancer.

      New medical necessity criteria — Effective for  dates of service beginning June 1, 2016

      Tysabri  (natalizumab)  

      Harvard Pilgrim has updated the medical necessity criteria for coverage of Tysabri (natalizumab) for the treatment of patients 18 and over with Crohn’s disease and multiple sclerosis.

      Effective June 1, 2016, coverage criteria for Tysabri (natalizumab) will require documentation of anti-JCV antibody testing. 

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      Network Matters Archives

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      HPHCURRENT EVENTS

      Medicare Prescriber Enrollment Deadline Updated

      CLINICIAN CORNER

      Reducing Preventable Readmissions in Medicare Advantage Population

      Clinical Policy and Prior Authorization Updates

      Update to Formulary Exception Request Process

      Verify Coverage Before Dispensing Medication Samples

      Massachusetts Providers: Enroll in Online Prescription Monitoring Program

      Complex Case Management Services

      Disease Management Programs that Reinforce Physician Treatment Plans

      Self-Harm and Alcohol Abuse Risks After Bariatric Surgery

      OFFICE ASSISTANT

      Reminder: Keep Panel Status Up to Date

      PUBLICATION INFORMATION

      Eric H. Schultz,
      President and Chief Executive Officer

      Robert Farias,
      Vice President, Network Services

      Annmarie Dadoly,
      Editor

      Joseph O'Riordan,
      Writer

      Kristin Edmonston,
      Production Coordinator