Prior Authorization and Notification Requirements for Durable Medical Equipment (DME) and Related Services
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Lists DME, prosthetic items, procedures and services that require prior authorization or notification from the Plan and describes applicable clinical references and submission pathways; applies to providers submitting claims for covered members.
No material clinical or coverage changes in this revision.
Prior Authorization and Coverage Criteria for DME and Related Services
Table 1 Prior Authorization Criteria
Covered when prior authorization is obtained and criteria from referenced sources are met
See specific MNGs on Provider Resource Center for item-level criteria
Table 1: Procedures with referenced criteria
Coverage determinations reference specified external and internal criteria sources for listed procedure groups.
See referenced MNGs and LCDs for full medical necessity criteria
Table 3: Behavioral health prior authorization
Behavioral health procedures requiring behavioral health department prior authorization.
See Psychological and Neuropsychological Testing and Assessment MNG and Transcranial Magnetic Stimulation MNG on Provider Resource Center
Table 4: Medicaid-only PA
Medicaid-only procedures requiring prior authorization via Precertification Operations.
See MassHealth references and the One Care/Medicaid MNGs on the Provider Resource Center
Table 4: Pharmacy-managed PA
Drug and therapy codes managed by Pharmacy UM require prior authorization and reference NCDs or internal MNGs.
Submit PA to Pharmacy UM (fax 617-673-0956); see Provider Resource Center MNGs for product-specific criteria
Table 5-8: Vendor Program PA
Vendor-managed programs require PA through the vendor.
See vendor websites (Evolent, Carelon, RADMD) and Provider Resource Center for vendor-specific instructions
Table 9: No prior authorization required
Codes not requiring prior authorization represent services considered medically necessary; post-service edits may apply.
See specific MNGs on the Provider Resource Center for coverage and documentation details (e.g., Breast Pumps, Cardiac Event Monitors, Absorbent Products)
Non-emergency medical transportation (ground/air) claims submitted with one of the listed modifiers do not require prior authorization. Specifically, PA is not required when the service is billed with any of these modifiers: DH, EH, GH, HD, HG, HH, HJ, JH, NR, PH, RH, RN. Coverage and billing follow the Medicare Benefit Policy Manual, Chapter 10 as the criteria reference.
Procedures identified as investigational in Table 6 are not covered by the Plan. The document directs providers to the Non-Covered Investigational Services Medical Necessity Guideline (MNG) on the Provider Resource Center for details and code-level information.
Table 6 lists procedure codes the Plan considers investigational and therefore not covered; providers should note that investigational items are managed separately from Table 1 coverage items. For related device and DME coding references (e.g., PAP devices, power mobility), see the applicable LCDs and MNGs cited elsewhere in Table 1.
Services designated as investigational in Table 6 are treated as non-covered (not medically necessary) under the Plan. Providers should consult the Non-Covered Investigational Services MNG for the definitive list of codes and the Plan's rationale for non-coverage.
CPT/HCPCS/ICD-10 Codes and Groupings
Prior Authorization Submission, Routing, and Provider Responsibilities
Prior Authorization/Notification Requirement
Prior authorization or notification must be obtained as a condition of payment. Supporting clinical documentation pertinent to the service request must be submitted with the prior authorization request.
- Supporting clinical documentation must be submitted to the Precertification Operations Department via fax: 857-304-6304.
- Prior authorization is required for the items and services listed in Table 1 and for other items in Tables 2–5 and Table 8 as specified in those tables.
- Some medical-benefit drugs and therapy codes are managed by Pharmacy UM and require prior authorization through Pharmacy Utilization Management (fax: 617-673-0956).
- Certain services are managed by vendor programs (e.g., Evolent, Carelon) and require prior authorization through those vendor programs per the table listings.
Prior Authorization Required for Table 1 Items
Prior authorization is required for the items and services listed in Table 1; requests may be submitted by fax to 857-304-6304.
- Table 1 lists DME, prosthetic items, procedures (e.g., Anterior Vertebral Body Tethering, Bariatric Surgery, Basivertebral Nerve Ablation, Blepharoplasty, CGM devices) that require prior authorization from the Precertification Operations Department.
- Providers should follow the referenced Medical Necessity Guidelines (MNGs) on the Provider Resource Center for specific coverage and authorization criteria.
Prior Authorization Required
Certain procedures, drugs, and services listed in Tables 1–5 and Table 8 require prior authorization from the specified department. Follow the departmental routing and fax numbers when submitting requests.
- Behavioral Health Department prior authorization requests (Table 2) may be submitted by fax to 857-304-6304.
- Medicaid-only prior authorizations (Table 3) require submission to the Precertification Operations Department per the table instructions.
- Drug and therapy codes managed by Pharmacy UM (Table 4) require prior authorization via Pharmacy Utilization Management (fax: 617-673-0956).
- Vendor-managed programs (Table 5) require prior authorization through the named vendor (e.g., Evolent, Carelon) per the table details.
Pharmacy Management / Potential Step Therapy
Some medical benefit drugs are managed by Pharmacy Utilization Management and may be subject to utilization management policies, including step therapy. Check the Provider Resource Center for the complete list of pharmacy-managed medical benefit drugs and the New to Market Drug MNG for newly introduced therapies.
- Pharmacy UM fax number for prior authorization requests: 617-673-0956.
- Examples of pharmacy-managed drugs that require PA include CAR T-cell therapies and other specified J/Q codes listed in Table 4; refer to the specific MNG for criteria.
PA and Coverage per Medical Necessity Guidelines
Prior authorization and coverage requirements for many listed procedures and HCPCS/CPT codes are defined in their respective Medical Necessity Guidelines (MNG) on the Provider Resource Center. In absence of an applicable external guideline (CMS/MassHealth), internal MNGs apply.
- Follow the referenced MNG for services listed in Tables 9 and other tables where a Coverage Guideline or MNG is cited.
- Services designated investigational in Table 6 are non-covered and may be denied; see the Non-Covered Investigational Services MNG for details.
Medical Necessity Criteria and DME Rules
DME Medical Necessity Criteria (general)
Equipment coverage is subject to referenced criteria sources (CMS LCD/NCD, MassHealth, InterQual, or internal criteria).
See corresponding MNGs on the Provider Resource Center for item-level details (e.g., power mobility, PAP devices, speech generating devices)
DME coverage per MNG
DME and related items in Table 9 are covered when medical necessity is met per the referenced MNGs.
Even when prior authorization is not required, providers must follow MNG documentation requirements and may be subject to post-service edits
Required Documentation and Post-Service Edits
Submit clinical documentation with prior authorization request to Precertification Operations Department via fax.
Submit supporting clinical documentation with the prior authorization request to the Precertification Operations Department via fax (857-304-6304).
Follow the coverage guideline in the referenced MNG; post-service edits may apply.
Follow the coverage guideline in the referenced Medical Necessity Guideline on the Provider Resource Center for each service; post-service edits may still apply.
Follow referenced MNG for required documentation and PA
Refer to the specific Medical Necessity Guideline on the Provider Resource Center for required documentation and prior authorization procedures for listed equipment and services (e.g., breast pumps, cardiac event monitors).
Reference Sources and Definitions
Rental vs Purchase and Replacement Policies
| Item | Rule / Notes |
|---|---|
| Rental & purchase rules for DME not specified in this document segment | |
| Consult the individual Durable Medical Equipment Medical Necessity Guideline (MNG) on the Provider Resource Center for rental vs. purchase determination and applicable billing rules |
| Item | Rule / Notes |
|---|---|
| Rental vs. purchase for items listed in this segment | |
| Not specified in this segment; providers should consult each DME MNG on the Provider Resource Center for rental versus purchase rules and any related documentation requirements |
Policy Background and Scope
When making coverage determinations the Plan relies on federal and state authoritative sources where available. This includes CMS National and Local Coverage Determinations and associated policy articles (NCDs/LCDs/LCAs), MassHealth medical necessity determinations when applicable, and InterQual or internal Medical Necessity Guidelines (MNGs) where CMS/MassHealth guidance is absent. Providers should follow the referenced LCD/NCD or MNG noted for each service in the tables.
Non-Covered and Investigational Services
Items and procedures identified as investigational in Table 6 are explicitly excluded from coverage by the Plan. Refer to the Non-Covered Investigational Services MNG on the Provider Resource Center for the complete list of investigational procedure codes and associated guidance.
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