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Clinical Policy and Prior Authorization Updates |
| Policy/procedure |
Description |
Additional resources |
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New coverage — Effective immediately. Prior authorization is not required. |
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Proton beam therapy
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Harvard Pilgrim recently updated our proton beam therapy medical policy to clarify that this therapy is medically necessary for malignancies in members under the age of 21. |
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Stem cell transplant
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Harvard Pilgrim recently updated our stem cell transplant medical policy to indicate that stem cell transplant is considered medically necessary for sickle-cell disease. As a result, Harvard Pilgrim covers allogeneic stem cell transplantation and related procedures for members with sickle-cell disease. |
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New medical policies created — Prior authorization is not required. |
Biofeedback
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Effective for dates of service beginning July 1, 2016 Harvard Pilgrim has developed a new medical policy that lists the conditions for which biofeedback (90901; 90911) is medically appropriate. Harvard Pilgrim considers biofeedback medically necessary for:
• Migraine and tension headaches
• Dyssynergic defecation
• Urinary incontinence |
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Non-invasive tests for hepatic fibrosis
Effective for dates of service beginning May 1, 2016 |
A new medical policy outlines coverage of non-invasive tests used to measure liver fibrosis. Harvard Pilgrim considers the following medically necessary to assess the degree of liver fibrosis and cirrhosis in members with chronic liver disease:
• Transient elastography (e.g. FibroScan)
• FibroTest-ActiTest
• HepaScore
• HCV-FibroSure
Because there is insufficient clinical evidence to support their use, Harvard Pilgrim considers the following not medically necessary to assess the degree of liver fibrosis to determine appropriate medication regimens in members with Hepatitis C Virus:
• FibroMAX
• FibroSpect
• FibroMeter
• NASH FibroSure
• HepaScore |
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Prenatal ultrasound
Effective for dates of service beginning May 1, 2016 |
Harvard Pilgrim’s Prenatal Ultrasound Medical Policy clarifies coverage of routine prenatal ultrasound. There is no change in coverage. Harvard Pilgrim covers:
• One routine prenatal ultrasound during the first trimester of pregnancy and one routine prenatal ultrasound during the second or third trimester of pregnancy in low-risk members.
• Prenatal ultrasound when medically necessary for clinical indications where the mother or fetus may be at risk.
Harvard Pilgrim considers either three-dimensional or four-dimensional obstetrical ultrasonography not medically necessary during pregnancy. |
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Vitamin D Screening and Testing
Effective for dates of service beginning July 1, 2016 |
Harvard Pilgrim has developed a policy that establishes the medical conditions for which Vitamin D screening and testing is medically necessary for members ages 18–65. Under this policy, Harvard Pilgrim does not consider routine screening for Vitamin D deficiency in healthy adults medically necessary. However, routine vitamin D screening is considered medically necessary for members under age 18 or over age 65.
Please keep this change in coverage in mind if you order Vitamin D screening as part of a routine panel of tests for your patients. |
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