harvard pilgrim DME prior auth Policy Update

Coverage Criteria and Policy Scope

General prior authorization criteria

Covered when prior authorization requirements are met for listed items and services in the respective tables

Table-based prior auth: Request must be for a code/item listed in the applicable table (Table 1 for DME/prosthetics/procedures, Table 2 for Behavioral Health, Table 3 for Pharmacy-managed drugs/advanced therapies, Table 4 for Vendor Managed Programs) and must include supporting clinical documentation; follow department-specific submission routes (Precertification Operations, Behavioral Health, Pharmacy Utilization Management, Vendor Program).

Prior authorization requests for Table 1 may be submitted by fax to 617-972-9409; vendor-specific portals or numbers (e.g., eviCore) apply where indicated.

Table-based coverage logic

Coverage stance and required actions by table

Table 3 - Specialized therapies: Lists cell and gene therapies and associated HCPCS/J/Q codes; coverage is governed by the cited Medicare NCDs/LCDs and product-specific medical necessity guidelines (MNG) on the Provider Resource Center.

Providers should follow the referenced NCD (e.g., CAR T-cell Therapy NCD 110.24) or the product MNG for clinical criteria.

Table 4 - Vendor-managed services: Codes managed by vendor programs (e.g., eviCore, Evolent) require prior authorization or prior notification through those vendor programs; includes PAP devices, sleep studies, interventional pain and spine procedures as listed.

Providers must submit prior notification for PAP therapy and sleep studies to eviCore via its website or by calling 888-511-0401.

Table 6 - Notification required for DME/prosthetics: Procedure codes in Table 6 require notification to the Precertification Operations Department; inpatient notifications may be faxed to 617-972-9590. InterQual and the CMS Medicare Benefit Policy Manual are used as evidence sources for medical necessity and level-of-care decisions.

Concurrent review may apply.

Table 8 - No prior authorization required: Codes listed in Table 8 do not require prior authorization from the Plan; these codes represent services considered medically necessary per referenced coverage guidelines. Post-service edits may apply.

See the Provider Resource Center MNGs cited for each service (e.g., Intravitreal Implants, Remote Patient Monitoring, EGD).

Unlisted procedure codes are included in Table 1 and must be reviewed against Medicare criteria rather than being granted blanket coverage. Examples of unlisted procedure codes enumerated in Table 1 include A9999, E0676, E1399, K0009, K0108, L0999, L1499, L2999, L3649, L3999, L7499, L5999, L8039, L8048, L8499, L8699, and L9900. For these codes the Plan relies on applicable CMS LCD/NCD guidance and billing/coding articles to determine medical necessity and coverage.

Procedure codes identified in Table 5 as "investigation" are considered investigational by the Plan and are not covered. Services billed with those codes will be handled as non-covered investigational services in accordance with the Plan's policies.

Table 5 lists procedure codes the Plan considers investigational and therefore not covered. The Table directs readers to the Medicare Non-Covered Investigational Services Medical Necessity Guideline (MNG) on the Provider Resource Center for the specific procedure code list and coverage details.

Items and procedures in Table 5 are investigational and therefore not medically necessary and not covered by the Plan. The policy references the Medicare Non-Covered Investigational Services MNG for details; claims submitted for services in Table 5 will be denied as non-covered investigational services per that guidance.

Code Lists and Tables

Covered / prior auth procedure and HCPCS/CPT codes (Table 1)mixedCovered

64628	Basivertebral nerve ablation
64629	Basivertebral nerve ablation
15820	Blepharoplasty
15821	Blepharoplasty
15822	Blepharoplasty
15823	Blepharoplasty
67900	Ocular procedure
67901	Ocular procedure
67902	Ocular procedure
67903	Ocular procedure

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1/9

Behavioral Health prior auth codes (Table 2)CPTCovered

96130	Psychological testing
96131	Psychological testing
96132	Neuropsychological testing
96133	Neuropsychological testing
96136	Psychological testing
96137	Psychological testing
96138	Psychological testing
96139	Psychological testing
96146	Psychological testing
90867	Transcranial magnetic stimulation - therapy code

1–10 of 12

1/2

Drug and therapy prior auth codes (Table 3)mixedCovered

Q2055	Abecma (CAR T)
J9029	Adstiladrin
J3490	Amtagvi (J3490 - unclassified drug)
Q2058	Aucatzyl (CAR T)
Q2054	Breyanzi (CAR T)
Q2056	Carvykti (CAR T)
J3392	Casgevy
A4238	CGM - Freestyle/Dexcom product
E2102	CGM - Freestyle/Dexcom product
J3403	Encelto

1–10 of 20

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Vendor managed program codes (Table 4)mixedCovered

E0601	CPAP device
E0470	BiPAP device
E0471	BiPAP device
A4604	CPAP/BiPAP supplies

Cell and Gene Therapy Codes (Table 3 additional)CPT

0037U	FoundationOne CDX
0242U	Guardant360
0026U	ThyroSeq

PAP device and supply codes (eviCore-managed, Table 4 additional)HCPCS

A7027	CPAP/BiPAP supply
A7028	CPAP/BiPAP supply
A7029	CPAP/BiPAP supply
A7030	CPAP/BiPAP supply
A7031	CPAP/BiPAP supply
A7032	CPAP/BiPAP supply
A7033	CPAP/BiPAP supply
A7034	CPAP/BiPAP supply
A7035	CPAP/BiPAP supply
A7036	CPAP/BiPAP supply

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Sleep study procedure codes (eviCore-managed, Table 4 additional)CPT

95805	Sleep study attended
95807	Sleep study attended
95808	Sleep study attended
95810	Sleep study attended
95811	Sleep study attended

No prior authorization required codes (Table 8)mixedCovered

67027	Intravitreal implant procedure
67028	Intravitreal implant procedure
J1096	Intravitreal corticosteroid insert
J7313	Intravitreal corticosteroid insert
J7311	Intravitreal corticosteroid insert
J7312	Intravitreal corticosteroid insert
J7314	Intravitreal corticosteroid insert
99091	Remote patient monitoring
99453	Remote patient monitoring
99454	Remote patient monitoring

1–10 of 27

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Facility/revenue codes (Table 6)Revenue

190	Skilled Nursing Facility - Level 1A

Power mobility battery prior auth — Batteries do not require prior authorization and are covered according to Medicare guidelines

Power mobility battery prior authBatteries do not require prior authorization and are covered according to Medicare guidelines

Use of InterQual — InterQual used with CMS Medicare Benefit Policy Manual to support medical necessity and level of care decisions

Use of InterQualInterQual used with CMS Medicare Benefit Policy Manual to support medical necessity and level of care decisions

Provider Requirements and Authorization Processes

Prior Authorization

Prior Authorization Required

Prior authorization is required for the items, services and procedure codes listed in the Plan tables (see Tables 1–4 and 6). Prior authorization requests must be submitted to the managing department or vendor listed for each table; supporting clinical documentation pertinent to the request must be included. Failure to obtain required prior authorization or to submit required notifications and clinical documentation may result in denial or non-payment.

Table-specific submission points: Precertification Operations Department (Table 1) — fax 617-972-9409; Behavioral Health Department (Table 2) — fax 617-972-9409; Pharmacy Utilization Management Department (Table 3) — fax 617-673-0956; Vendor-managed programs (Table 4) — follow vendor processes (see Evolent and eviCore contact methods); Inpatient notifications (Table 6) — fax 617-972-9590.
Providers must verify any required prior authorization as a condition of payment even when another provider or supplier will obtain the authorization.
When CMS/MassHealth guidance exists, the Plan uses those criteria (NCDs, LCDs, LCAs, Medicare Benefit Policy Manual); when such guidance does not exist the Plan’s medical necessity guidelines apply.

Prior Authorization

Vendor-Managed Prior Authorization

Clinical Necessity References and Criteria

DME medical necessity references

Medical necessity references and criteria sources for equipment types are primarily CMS NCDs/LCDs and internal MNGs; specific references are listed per equipment type in Table 1.

DME medical necessity references: Coverage and medical necessity for listed DME items follow CMS NCDs/LCDs (examples include: LCD Glucose Monitors L33822 for CGMs; NCD Mobility Assistive Equipment (MAE) 280.3 and LCD L33789 for power mobility devices; NCD Pneumatic Compression Devices 280.6 for pneumatic compression devices; NCD Osteogenic Stimulators 150.2 and LCD L33796 for osteogenesis stimulators).

Providers should refer to the cited LCD/NCD and Provider Resource Center MNGs for detailed clinical criteria.

DME medical necessity references

Medical necessity is supported by CMS criteria and InterQual where noted.

PAP therapy and sleep testing: PAP devices, supplies and sleep study services are governed by CMS NCDs/LCDs and require vendor prior notification/authorization as specified; eviCore manages sleep diagnostic and therapy management for Tufts Medicare Preferred HMO members.

Rental, Purchase and Replacement Rules

Item	Coverage status	Notes
Power mobility device batteries
Applies to batteries for power wheelchairs and power operated vehicles (see codes K0010-K0014, E1230, E2298, etc.)
Batteries do not require prior authorization and are covered according to Medicare guidelines (NCD - Mobility Assistive Equipment 280.3; LCD L33789).

Topic	Details / policy note
Rental vs purchase rules
No explicit rental versus purchase rules are provided in the excerpt. The document's approval and revision history records multiple coding and table updates that affect prior authorization placement and code status (see Approval And Revision History entries).
Recent coding and table movements: examples include coding updates to Aucatzyl (Q2058) effective July 1, 2025 and multiple PA table changes noted throughout 2025 (see Approval And Revision History for specific effective dates and code movements).

inv-38: Replacement

NoteReplacement rules not provided in available document excerpts; refer to manufacturer guidance, Medicare NCD/LCDs, or the full policy for specific replacement intervals and conditions.

Common sourcesReplacement intervals, when specified, typically follow Medicare LCD/NCD criteria and device-specific medical necessity guidelines.

Provider actionIf replacement is requested, include supporting clinical documentation and reference applicable NCD/LCD or MNG in the PA submission.

Submission, Notifications and Supporting Documentation

Documentation Required

Fax required clinical documentation with PA requests

Submit clinical documentation pertinent to prior authorization requests using the fax numbers provided in the relevant table; Table 1 PA requests may be submitted by fax to 617-972-9409.

Supporting clinical documentation is required for PA determination.
Table-specific fax numbers appear in the tables (e.g., Table 1 fax 617-972-9409).

Documentation Required

Fax inpatient notifications to Precertification Operations (Table 6)

Submit inpatient notifications for codes listed in Table 6 by fax to Precertification Operations at 617-972-9590 and follow InterQual as indicated to support medical necessity and level-of-care decisions.

InterQual is used along with the CMS Medicare Benefit Policy Manual for initial and concurrent review.
Use the Table 6 notification fax number: 617-972-9590.

Policy Background and Sources

For Dual Product Eligible members the Plan uses CMS National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), Medicare manuals and MassHealth determinations where applicable to inform coverage decisions. When CMS or MassHealth guidance is not available, internally developed medical necessity guidelines (MNGs) are used. InterQual is referenced as an additional source of clinical evidence for level-of-care and medical necessity determinations in select services.

Definitions and Program Notes

inv-31: InterQual referenced as a source of medical evidence

RoleInterQual is referenced as a source of medical evidence used alongside the CMS Medicare Benefit Policy Manual to support medical necessity and level-of-care determinations.

Application areasSpecifically cited for inpatient and skilled nursing facility level-of-care decisions (Table 1 and Table 6).

Review processesUsed for initial and concurrent review processes as noted in the notification and PA pathways.

Provider implicationProviders should include clinical information that aligns with InterQual and CMS manual criteria when submitting notifications or PA requests.

inv-32: Vendor Managed Program

DefinitionVendor Managed Program: services and codes managed by third-party vendors (e.g., eviCore, Evolent) that require prior authorization or notification through the vendor's process.

Non-covered and Investigational Services

Procedures listed in Table 5 are considered investigational and are not covered by the Plan. Providers should consult the Medicare Non-Covered Investigational Services MNG for the detailed list of codes and the rationale for noncoverage.

Investigational services listed in Table 5 are non-covered under this policy. The Table points providers to the Medicare Non-Covered Investigational Services Medical Necessity Guideline (MNG) for the definitive list and coverage policy referenced by the Plan.

OpenPayer

Prior authorization, notification, and no prior authorization medical necessity guidelines (DME-focused)