As you may know, Point32Health has a partnership with Evolent to oversee prior authorization programs for certain services, including cardiac diagnostic tests and interventional procedures; high-tech diagnostic imaging; select joint procedures; spine surgery and cervical spine procedures; and outpatient interventional spine pain management services.
Effective for dates of service beginning March 1, 2025, Point32Health and Evolent are adding prior authorization requirements for a number of additional cardiac services for Tufts Health Direct, Tufts Health Plan Together, Tufts Health Plan RITogether, and Tufts Health One Care (these services already require prior authorization through Evolent for Harvard Pilgrim Commercial and Tufts Health Plan Commercial plans):
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- Fractional Flow Reserve CT (CPT code 75580)
- Cardiac Resynchronization Therapy (CRT) (CPT codes 33221, 33224, 33225, 33231)
- Implantable Cardioverter Defibrillator (ICD) (CPT codes 33230, 33240, 33249)
- Pacemaker (CPT codes 33206, 33207, 33208, 33212, 33213)
- Transthoracic Echocardiology (TTE) (CPT codes 93303, 93304, 93306, 93307, 93308, as well as the add-on codes +93320, +93321, +93325, +93356)
- Transesophageal Echocardiology (TEE) (CPT codes 93312, 93313, 93314, 93315, 93316, 93317, 93318, and the add-on codes +93320, +93321, +93325)
- Stress Echocardiography (CPT codes 93350, 93351, and the add-on codes +93320, +93321, +93325, + 93352, +93356)
- Heart Catheterization (CPT codes 93452, 93453, 93454, 93455, 93456, 93457, 93458, 93459, 93460, 93461, and the add-on codes +93462, +93463, +93464, +93565, +93566, +93567, +93568)
For more information, including guidance on how to request prior authorization and access utilization review matrices, please refer to the resources identified on the Evolent vendor page on Point32Health’s Provider website.