Noncovered Investigational Services MNG

CarePartners of Connecticut has developed Medical Necessity Guidelines (MNG) for Noncovered Investigational Services, effective for dates of service beginning April 1, 2025. 

The new MNG documents services and codes for which Point32Health will not provide reimbursement in a centralized location as a comprehensive provider reference tool. As an example, services outlined as non-covered include some proprietary lab codes, select new bioengineered skin substitutes, and category III codes, among others.

At a minimum, CarePartners of Connecticut provides coverage for all services and items covered by Medicare. We use local coverage determinations (LCDs), national coverage determinations (NCDs), and Medicare interpretive manuals such as the Medicare Benefit Policy Manual to make coverage determinations. 

For items that are considered experimental/investigational and consequently noncovered by the Centers for Medicare and Medicaid Services, the newly developed MNG references the applicable LCD or NCD that outlines Medicare’s stance. If Medicare has not issued a definitive stance, CarePartners of Connecticut will determine coverage based on medical necessity, safety, and efficacy using reliable evidence as outlined in the MNG.

CarePartners of Connecticut members are being informed of the new MNG via mailings, which will begin in mid-February; as a result, you may receive questions from your patients. For complete information, please refer to the Noncovered Investigational Services Medical Necessity Guidelines.