CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Hemic and Lymphatic System Surgical Services

Defines coverage and administrative requirements for surgical services and procedures of the spleen, lymph nodes, and lymphatic channels for Neighborhood Health Plan of Rhode Island members in specified benefit packages.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyHemic and Lymphatic System Surgical Services

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJun 22, 2010

Next Review DateN/A

Key ActionObtain medical review and prior authorization for all inpatient hospitalizations related to hemic and lymphatic surgical services before admission.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

All inpatient hospitalizationsrequire prior authorization and medical review

Experimental/non‑FDA servicesnot covered except in cancer treatment

RIte Care, CSHCN, Substitute Care, Rhody Health Partners, Rhody Health OptionsBenefit packages listed

Coverage criteria and exclusions

Prior Authorization Requirement

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Experimental and Investigational Services

Coverage exclusions related to experimental or non-FDA approved services:

ALL of the following

Procedures deemed experimental or investigational are not covered
Exception
- Experimental or non-FDA approved services used in the treatment of cancer may be covered

Actions required of ordering and billing providers

Prior Authorization

Prior authorization for inpatient hospitalizations

Obtain medical review and prior authorization for all inpatient hospitalizations related to hemic and lymphatic surgical services before admission.

Documentation Required

Ordering requirement for transplant coverage

Ensure transplant services are ordered by an in‑plan physician to qualify for coverage for Rhody Health Plan members.

Denial Risk

Experimental/non‑FDA procedures

Expect denial for services deemed experimental or not FDA‑approved unless they are used in the treatment of cancer.

Clinical and administrative background

This policy addresses hemic and lymphatic services, defined as surgical services and procedures of the spleen, lymph nodes, and lymphatic channels, and applies to specified Neighborhood Health Plan of Rhode Island benefit packages including RIte Care, Children with Special Health Care Needs, Substitute Care, Rhody Health Partners, and Rhody Health Options Phase One. It defines both coverage and administrative requirements for these inpatient surgical services.

All inpatient hospitalizations for hemic and lymphatic surgical services require medical review and prior authorization before admission. Providers must obtain prior authorization for inpatient care to establish benefit applicability and to avoid denial of claims.

Services that are experimental or not FDA‑approved are not covered under this policy, with a specific exception: experimental or non‑FDA approved services may be considered when they are used in the treatment of cancer.

A special note on transplant services: transplant procedures are covered for Rhody Health Plan members only when they are ordered by an in‑plan physician. Additionally, Extended Family Planning (EFP) members are excluded from the comprehensive benefit package and therefore are not covered under this policy.

Quick policy highlights

Key Policy Statistics

Prior authorization and medical reviewAll inpatient hospitalizations require medical review and prior authorization.

Experimental/non‑FDA servicesProcedures deemed experimental or non‑FDA approved are not covered except when used in the treatment of cancer.

Benefit packages listedRIte Care, Children with Special Health Care Needs (CSHCN), Substitute Care, Rhody Health Partners, Rhody Health Options Phase One.