Updates to Non-Covered Services Medical Policy

Harvard Pilgrim is updating our commercial New Technology Assessment and Non-Covered Services Medical Policy, effective for dates of service beginning Nov. 1, 2021, to include the following services and technologies as non-covered:

  • VenaSeal Closure System
  • Micro-Ultrasound Diagnosis for Prostate Cancer
  • Prospera
  • MyoPro Orthosis for Upper Extremity
  • SPiN Thoracic Navigation System
  • InterAtrial Shunt Device for Heart Failure
  • NeoGEN Series System
  • Remote Temperature Monitoring Telemetry Devices

In addition, the following HCPCS and CPT codes will no longer be covered:

  • K1016 – Transcutaneous electrical nerve stimulator for electrical stimulation of the trigeminal nerve
  • K1017 – Monthly supplies for use of device coded at K1016
  • K1018 – External upper limb tremor stimulator of the peripheral nerves of the wrist
  • 0613T – Percutaneous transcatheter implantation of interatrial septal shunt device, including right and left heart catheterization, intracardiac echocardiography, and imaging guidance by the proceduralist, when performed
  • 36482 – Endovenous ablation therapy of incompetent vein, extremity, by transcatheter delivery of a chemical adhesive (e.g., cyanoacrylate) remote from the access site, inclusive of all imaging guidance and monitoring, percutaneous; first vein treated
  • 36483 – Endovenous ablation therapy of incompetent vein, extremity, by transcatheter delivery of a chemical adhesive (e.g., cyanoacrylate) remote from the access site, inclusive of all imaging guidance and monitoring, percutaneous; subsequent vein(s) treated in a single extremity, each through separate access sites (List separately in addition to code for primary procedure)

For complete information, please refer to the updated New Technology Assessment and Non-Covered Services Medical Policy.


Publication Information

Annmarie Dadoly,
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Joseph O’Riordan,
Writer

Kristin Edmonston,
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