Point32Health continually evaluates our utilization management programs and the prior authorization requirements we have in place to promote medical necessity and clinical appropriateness and alignment with evidence-based guidelines, so that we can ensure our members receive the care that is best for them while managing health care costs.
To that end, effective Jan. 1, 2025, we’re instituting prior authorization requirements for a number of services/codes for our Tufts Medicare Preferred and Tufts Health Plan Senior Care Options products, as identified in the chart below. For additional details, refer to the Medical Necessity Guidelines page on our Point32Health provider website, where you can find coverage and prior authorization criteria for our Harvard Pilgrim and Tufts Health Plan lines of business. You’ll also find an updated Tufts Medicare Preferred Prior Authorization, Notification, and No Prior Authorization List and Tufts Health Senior Care Options Prior Authorization, Notification, and No Prior Authorization List on our Point32Health Prior Authorization page.
| Service | Coding/prior authorization change effective Jan. 1, 2025 |
| Levels of Care
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Acute Inpatient Rehabilitation will be added to prior authorization using Medicare Benefit Policy Manual Chapter 1 for prior authorization coverage criteria. |
| Non-Emergent Medical Transportation (Ambulance)
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For Tufts Medicare Preferred only, we will follow Medicare Benefit Policy Manual Chapter 10 for criteria, and will require prior authorization for the following codes: A0426, A0428, A0430, A0435.
Refer to this article for additional details.
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| Intensity-Modulated Radiation Therapy | Prior authorization will be required for the following codes:
Refer to the internal MNG for prior authorization and coverage criteria. Please note that members receiving intensity-modulated radiation therapy (IMRT) prior to Jan. 1, 2025 will not be impacted by this new prior authorization requirement. All members starting IMRT on or after Jan. 1, 2025 will require prior authorization. In alignment with the Out of Network at the In Network Level of Benefit and Continuity of Care Medical Necessity Guidelines, all members who are in an active course of IMRT prior to Jan. 1, 2025 will have 90 days’ continuity of care starting Jan. 1, 2025 and do not need to obtain a prior authorization for that course of treatment. |
| Proton Beam Therapy
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We will follow Local Coverage Determination (LCD) L35075 and associated article A56827 for prior authorization review criteria, and prior authorization will be required for codes 77520, 77522, 77523, and 77525.
Please note that members receiving proton beam therapy prior to Jan. 1, 2025 will not be impacted by this new prior authorization requirement. All members starting proton beam therapy on or after Jan. 1, 2025 will require prior authorization. In alignment with the Out of Network at the In Network Level of Benefit and Continuity of Care Medical Necessity Guidelines, all members who are in an active course of proton beam therapy prior to Jan. 1, 2025 will have 90 days’ continuity of care starting Jan. 1, 2025 and do not need to obtain a prior authorization for that course of treatment. |
| Procedures for the Treatment of Symptomatic Varicose Veins
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We will follow LCD L34536 and LCD L33575 (associated articles A56914, A52870) for prior authorization review criteria, and prior authorization will be required for the following codes: 36465, 36466, 36468, 36471, 36473, 36474, 36475, 36476, 36478, 36479, 36482, 36483, 37500, 37700, 37718, 37722, 37735, 37760, 37761, 37765, 37766, 37780, 37785, 37799, 93970, 93971. |
| Transurethral Waterjet Ablation of the Prostate
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Prior authorization will be required for codes C2596 and 0421T, and we will follow LCD L38682 and associated article A5209 for coverage criteria.
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| Blepharoplasty, Blepharoptosis, and Brow Lift
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We will follow LCD L34528 and associated article A456908 for prior authorization review criteria, and prior authorization will be required for the following codes: 15820, 15821, 15822, 15823, 67900, 67901, 67902, 67903, 67904, 67906, 67908. |
| Reconstructive and Cosmetic Surgery
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We will follow LCD L39051 and associated article A58774 for prior authorization criteria for breast reduction, rhinoplasty, gynecomastia surgery, and panniculectomy, and prior authorization will be required for the following codes: 15830, 15847, 15877, 19318, 19300, 30400, 30410, 30420, 30430, 30435, 30450, 30460, 30462. |
| Guardant360 CDx
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We will follow NCD 90.2 for prior authorization criteria, and prior authorization will be required for code 0242U for the Guardant360 CDx test. |
| Epidural Steroid Injections for Pain Management
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We will follow LCD L39036 and associated article A58745 for prior authorization criteria, and prior authorization will be required for codes 62321, 62323, 64479, 64480, 64483, and 64484. |
| Percutaneous Vertebral Augmentation (PVA) for Osteoporotic Vertebral Compression Fracture
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We will follow LCD L33569 and associated article A56178 for prior authorization coverage criteria, and prior authorization will be required for codes 22510, 22511, 22512, 22513, 22514, and 22515. |
| Lumbar Spinal Fusion
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We will follow LCD L37848 and associated article A56396 for prior authorization criteria, and prior authorization will be required for codes 22533, 22558, 22612, 22630, and 22633. |
| Cervical Fusion
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We will follow LCD L39770 and associated article A59632 for prior authorization criteria, and prior authorization will be required for the following codes: 22548, 22551, 22552, 22554, 22590, 22595, 22600, 22800, 22802, 22808, 22810, 22812. |
| Removal of Benign Skin Lesions
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Codes 17000, 17003, 17004, 17100, 17111 will be covered only when submitted for certain diagnoses, following guidance in CMS article A54602. See MNG for details, including a list of covered ICD-10 codes. |
| Genetic Testing
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We will follow LCD L35000 and associated article A56199 for prior authorization. See MNG for more details, including codes requiring authorization. |