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

April 2016

Clinical Policy and Prior Authorization Updates


Harvard Pilgrim regularly reviews clinical literature to create new medical policies or update existing ones. 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 coverage — Effective immediately. Prior authorization is not required.

    Proton beam therapy

    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. 

    Stem cell transplant

    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. 

      New medical policies created — Prior authorization is not required.

      Biofeedback

      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 

      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

      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.

      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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