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

June 2016

Clinical Policy and Prior Authorization Updates


Harvard Pilgrim regularly reviews clinical literature, best practices, and our existing clinical policies; based on this information, Harvard Pilgrim creates new policies or updates existing ones. The chart below summarizes upcoming policy and procedure changes. 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 inquiries — 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 or Expanded Coverage — Effective for dates of service beginning July 1, 2016. Prior authorization is not required.

      Darzalex (daratumumab)

      Harvard Pilgrim’s new medical policy outlines coverage for the new-to-market drug Darzalex. Harvard Pilgrim covers Darzalex for the treatment of multiple myeloma in accordance with FDA-approved labeling for members who:

      1. Received at least 3 prior lines of therapy for multiple myeloma including protease inhibitor (PI) and an immunomodulatory agent; or
      2. Refractory to both a PI and an immunomodulatory agent.

      Portrazza (necitumumab)

      Harvard Pilgrim’s new medical policy outlines coverage for the new-to-market drug Portrazza (necitumumab). Harvard Pilgrim covers Portrazza for the treatment of metastatic squamous non-small cell lung cancer in combination with gemcitabine and cisplatin, in accordance with FDA-approved labeling.

        Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy

        Based on clinical research, Harvard Pilgrim has expanded its coverage of stereotactic radiosurgery and stereotactic body radiation therapy. We have updated our Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy Medical Policy to include the additional covered codes.

          New Medical Policies

          Optical Coherence Tomography (Anterior Segment)

          Effective for dates of service beginning July 1, 2016 

          Harvard Pilgrim has developed a new medical policy on optical coherence tomography (OCT), a procedure used to produce high resolution cross-sectional imaging of the eye. OCT is commonly used to evaluate the posterior segment of the eye and has also been proposed to evaluate the anterior segment. Based on clinical literature, Harvard Pilgrim considers OCT of the anterior segment  investigational/experimental, and does not provide coverage. Harvard Pilgrim does provide coverage for OCT for the posterior segment.

          Ketamine HCI for Treatment of Psychiatric Disorders and Pain Management

          Effective for dates of service beginning Sept. 1, 2016 

          Harvard Pilgrim has developed a new medical policy to clarify the coverage of ketamine hydrochloride, a rapid-acting anesthetic drug. Increasingly ketamine HCI is being used for off-label treatment of psychiatric disorders and pain management. Harvard Pilgrim considers the off-label use of ketamine hydrochloride to treat any form of depression, psychiatric disorder, or chronic pain investigational/experimental and unproven.
          Use of ketamine for the induction of anesthesia or for conscious sedation for minor surgical procedures that do not require skeletal muscle relaxation is considered medically necessary.

          Policy Retired — Effective for dates of service beginning July 1, 2016. Prior Authorization no longer required.

          Knee Arthroscopy

          Harvard Pilgrim is retiring the Knee Arthroscopy Medical Review Criteria policy. Prior authorization is no longer required for knee arthroscopy services.

          Shoulder Arthroscopy

          Harvard Pilgrim is retiring the Shoulder Arthroscopy Medical Review Criteria policy. Prior authorization is no longer required for shoulder arthroscopy services.

          Policy Reviewed and Updated. No change in coverage/non-coverage.

          Platelet-rich Plasma Injections

          Effective for dates of service beginning June 15, 2016

          Harvard Pilgrim’s policy on Platelet-rich Plasma Injections remains the same; Harvard Pilgrim does not cover these treatments, as they are considered investigational and unproven.  Harvard Pilgrim removed references to dry-needling from the policy, however, as it may be covered in the scope of physical therapy.

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