Prior authorization and notification requirements for DME, prosthetics, procedures and related services
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Lists services, durable medical equipment (DME), prosthetic items, and procedure codes that require prior authorization or notification from Point32Health (Harvard Pilgrim), and describes which criteria sources are used for coverage determinations. Affects providers submitting claims or authorization requests for affected members.
Added S5100, S5101, S5102 with modifier CG to LTSS MNG effective April 1, 2026.
Removed Roctavian from table 4 because it has been removed from the market effective May 1, 2026.
Added code 43249 to Upper Gastrointestinal Endoscopy MNG effective June 1, 2026.
Added multiple procedure codes (21175, 21270, 53430, 54350) to Gender Affirming Services MNG effective June 1, 2026.
Updated prior authorization and coding lists across multiple dates (2024–2026) including additions and removals of codes and PA requirements.
Coverage Criteria and Referenced Sources
General coverage and criteria sources
Covered when medical necessity criteria from the referenced source are met for the listed services and codes
See Table 1 for item-specific criteria sources and MNGs on the Provider Resource Center.
Specific MNGs referenced in Table 1 provide detailed clinical criteria.
Prior authorization with referenced external criteria
Services listed are subject to the referenced criteria:
See individual MNGs/LCDs for exact inclusion/exclusion and detailed medical necessity criteria.
Behavioral Health prior authorization
Behavioral health services in Table 3 require prior authorization and are evaluated with Behavioral Health InterQual criteria where noted.
Submit prior auth to Behavioral Health Department fax 857-304-6304.
Pharmacy prior authorization and referenced criteria
Drugs and therapy codes in Table 4 require prior authorization from Pharmacy Utilization Management and are evaluated using specified NCDs or referenced MNGs.
Submit prior auth to Pharmacy Utilization Management fax 617-673-0956.
Vendor-managed authorization
Certain services are managed by vendor programs and require authorization via those vendors
See vendor sites or Carelon for coding and criteria details.
Notification and no-prior-auth categories
Some codes require notification only or do not require prior authorization.
Follow notification routing in Table 7 and consult Table 9 MNGs for coverage detail.
Covered when MNG criteria are met
Coverage for the listed procedures is governed by their specific Medical Necessity Guidelines (MNG) on the Provider Resource Center.
Providers must consult the specified MNG (e.g., Enteral Nutrition, FMT, HIPEC, Intravitreal Implants, Remote Patient Monitoring) for full criteria.
The Plan identifies certain Home and Community Based Services under Flexible Benefits as not covered for Tufts Health One Care. Specific procedure and HCPCS codes are listed in Table 1 (examples include PAP devices and power mobility device code groupings shown in Table 1); providers should reference Table 1 for the full code list and the associated coverage determinations.
Procedures and codes designated as investigational in Table 6 are not covered by the Plan. See the Non-Covered Investigational Services Medical Necessity Guideline (MNG) on the Provider Resource Center for the complete list of codes and rationale; claims for these investigational procedures will be denied if billed as covered services.
Per the approval history, Roctavian has been removed from Table 4 because it was removed from the market effective May 1, 2026. Providers should no longer submit prior authorization requests for Roctavian under Table 4 and should consult the Pharmacy Utilization Management processes for any replacement therapy coverage questions.
Cosmetic and reconstructive procedures are addressed by referenced criteria sources (CMS, MassHealth, InterQual, or internal criteria) and specific codes are identified in Table 1. Some procedures commonly considered cosmetic (for example, rhinoplasty, gynecomastia repair, panniculectomy, scar revision, labiaplasty and hair removal) are subject to the Reconstructive and Cosmetic Surgery MNG and may be non-covered when criteria or diagnosis codes do not support medical necessity. Providers should consult the Reconstructive and Cosmetic Surgery MNG on the Provider Resource Center for applicable documentation and coverage rules.
Investigational services listed in Table 6 are explicitly identified as not covered (not medically necessary) by the Plan. Providers must consult the Non-Covered Investigational Services MNG for the definitive list of investigational codes and for guidance on denials related to these services.
Codes and services may be moved between prior authorization lists and covered/no-prior-auth lists over time; such changes are implemented via table updates described in the approval and revision history. Providers must confirm the current table placement to determine whether a code requires prior authorization, notification, or no prior authorization and follow the table-specific instructions and referenced MNGs for documentation requirements.
Codes and Code Groups (CPT / HCPCS / ICD-10)
| 0446T | Continuous Glucose Monitoring and Diabetes Management Device |
| 0447T | Continuous Glucose Monitoring and Diabetes Management Device |
| 0448T | Continuous Glucose Monitoring and Diabetes Management Device |
| A4238 | CGM supply |
| A4239 | CGM supply |
| A9274 | CGM transmitter or supply |
| A9276 | CGM supply |
| A9277 | CGM supply |
| A9278 | CGM supply |
| E2103 | External insulin pump or infusion device component |
| K0010 | Standard wheelchair code range example |
| K0011 | Standard wheelchair code range example |
| K0012 | Standard wheelchair code range example |
| K0013 | Standard wheelchair code range example |
| K0014 | Standard wheelchair code range example |
| K0800 | Power operated vehicle (POV) base |
| K0801 | Power operated vehicle (POV) base |
| K0802 | Power operated vehicle (POV) base |
| 37700 | Ligation and Division +/- Stripping or Excision, Lower Extremity Superficial Vein |
| 37718 | Ligation and Division +/- Stripping or Excision, Lower Extremity Superficial Vein |
| 37722 | Ligation and Division +/- Stripping or Excision, Lower Extremity Superficial Vein |
| 37780 | Ligation and Division +/- Stripping or Excision, Lower Extremity Superficial Vein |
| 37785 | Ligation and Division +/- Stripping or Excision, Lower Extremity Superficial Vein |
| 37735 | Subfascial Endoscopic Perforator Surgery (SEPS) |
| 37760 | Subfascial Endoscopic Perforator Surgery (SEPS) |
| 36465 | Sclerotherapy, Lower Extremity Superficial Tributary Varicose Vein |
| 36466 | Sclerotherapy, Lower Extremity Superficial Tributary Varicose Vein |
| 36470 | Sclerotherapy, Lower Extremity Superficial Tributary Varicose Vein |
| 33940 | Heart transplant procedure code |
| 33944 | Heart transplant procedure code |
| 33945 | Heart transplant procedure code |
| 44132 | Small bowel procedures (transplant related) |
| 44133 | Small bowel procedures (transplant related) |
| 44135 | Small bowel procedures (transplant related) |
| 44136 | Small bowel procedures (transplant related) |
| 44715 | Small bowel procedures (transplant related) |
| 44720 | Small bowel procedures (transplant related) |
| 44721 | Small bowel procedures (transplant related) |
| 61796 | Stereotactic Radiosurgery |
| 61797 | Stereotactic Radiosurgery |
| 61798 | Stereotactic Radiosurgery |
| 63620 | Stereotactic Radiosurgery |
| 63621 | Stereotactic Radiosurgery |
| 77371 | Stereotactic Body Radiotherapy |
| 77372 | Stereotactic Body Radiotherapy |
| 77373 | Stereotactic Body Radiotherapy |
| 77432 | Stereotactic Radiation Therapy |
| 77435 | Stereotactic Radiation Therapy |
| 96130 | Psychological and Neuropsychological Testing and Assessment |
| 96131 | Psychological and Neuropsychological Testing and Assessment |
| 96132 | Psychological and Neuropsychological Testing and Assessment |
| 96133 | Psychological and Neuropsychological Testing and Assessment |
| 96136 | Psychological and Neuropsychological Testing and Assessment |
| 96137 | Psychological and Neuropsychological Testing and Assessment |
| 96138 | Psychological and Neuropsychological Testing and Assessment |
| 96146 | Psychological and Neuropsychological Testing and Assessment |
| 90867 | Transcranial Magnetic Stimulation (TMS) |
| 90868 | Transcranial Magnetic Stimulation (TMS) |
| T4521 | Absorbent Products |
| T4522 | Absorbent Products |
| T4523 | Absorbent Products |
| T4524 | Absorbent Products |
| T4525 | Absorbent Products |
| T4526 | Absorbent Products |
| T4527 | Absorbent Products |
| T4528 | Absorbent Products |
| T4529 | Absorbent Products |
| T4530 | Absorbent Products |
| B4105 | Enteral nutrition procedure code listed in Table 9 |
| B4149 | Enteral nutrition procedure code listed in Table 9 |
| B4150 | Enteral nutrition procedure code listed in Table 9 |
| B4152 | Enteral nutrition procedure code listed in Table 9 |
| B4153 | Enteral nutrition procedure code listed in Table 9 |
| B4154 | Enteral nutrition procedure code listed in Table 9 |
| B4155 | Enteral nutrition procedure code listed in Table 9 |
| B4157 | Enteral nutrition procedure code listed in Table 9 |
| B4158 | Enteral nutrition procedure code listed in Table 9 |
| B4159 | Enteral nutrition procedure code listed in Table 9 |
Provider Actions, Prior Authorization, and Routing
Prior Authorization Required
Prior authorization is required for many services, items, drugs and procedures listed in Tables 1–7. Failure to obtain required prior authorization or to submit supporting clinical documentation may result in claim denial or delayed processing.
- Prior authorization required for the prosthesis and DME codes listed in Table 1 — requests must be submitted to the Precertification Operations Department.
- Prior authorization required for listed procedure codes routed to other departments as noted in Tables 2–5 and Table 7 (Behavioral Health Department, Pharmacy Utilization Management, Vendor Program, etc.).
- Pharmacy-managed drugs and specialty therapies listed in Table 4 require prior authorization through the Pharmacy Utilization Management Department.
- Procedures and codes listed as investigational in Table 6 are not covered and will be denied.
Submission of Supporting Clinical Documentation
Supporting clinical documentation pertinent to the service request must be submitted with the prior authorization. Include relevant medical records, test results, operative reports, and rationale describing medical necessity.
- Failure to provide required supporting documentation may result in denial.
- Providers should reference the applicable Medical Necessity Guideline (MNG) on the Provider Resource Center for specific documentation and clinical criteria requirements.
Where to Send Prior Authorization Requests
Where to send prior authorization requests depends on the table and managing department. Use the fax numbers below and route requests to the managing department shown for the service or code.
- Precertification Operations Department (Tables 1, 3, and Table 7 notifications): fax 857-304-6304.
- Pharmacy Utilization Management (Table 4 — drugs and specialty therapies): fax 617-673-0956.
- Behavioral Health Department (Table 2 and Table 8 notifications): fax 857-304-6304.
- Vendor Program managed services (Table 5): follow vendor-specific submission instructions (see table entry and vendor websites referenced in policy).
Investigational / Not Covered
Investigational / Not Covered: Procedures and services identified as investigational in Table 6 are not covered by the Plan and will be denied. Providers should not submit prior authorization for investigational services unless otherwise directed by policy.
- See the Non-Covered Investigational Services MNG on the Provider Resource Center for full details and code lists.
Background and Policy Basis
Coverage determinations are based on authoritative external and internal criteria. The Plan uses CMS NCDs/LCDs/LCAs, MassHealth medical necessity determinations, InterQual®, and internal Medical Necessity Guidelines (MNGs) as the primary sources for evaluating medical necessity across the listed services and codes. Where a table or code references a specific MNG or CMS/LCD/NCD, that document contains the detailed inclusion/exclusion criteria that govern coverage decisions.
Definitions and Criteria Sources
Medical Necessity Rules for DME and Prosthetics
DME medical necessity
DME coverage is subject to device-specific CMS, LCD, NCD, InterQual, MassHealth or internal criteria as listed
See Power Mobility Devices LCD and related MNG.
Refer to the CGM and glucose monitor MNGs on the Provider Resource Center.
DME medical necessity via referenced MNGs
Coverage for DME items is governed by the referenced MNGs for each item listed in Table 9.
See Provider Resource Center MNGs for exact clinical/documentation criteria.
Prosthetics and complex component management
Medical necessity and PA rules for prosthetics and DME are controlled by table listings and referenced MNGs.
Providers should consult updated Table 1 and associated MNG for specific PA and coverage criteria and documentation requirements.
Rental, Purchase and Capped Rental Rules
| Device / Category | Rental vs Purchase Rule |
|---|---|
| Power wheelchairs, power operated vehicles (POVs), mobility devices | |
| Refer to the device-specific Medical Necessity Guideline (MNG) and applicable CMS LCD/NCD for rental vs purchase rules (e.g., Medicare PMD policies). Prior authorization is required per Table 1 where indicated; follow the referenced MNG on the Provider Resource Center for determination of rental versus purchase and Medicare rental caps. |
| Rule scope | Guidance |
|---|---|
| Individual DME items listed across tables (e.g., Table 9 items and other DME in Tables 1–7) | |
| Refer to each item's Medical Necessity Guideline (MNG) for specific rental versus purchase rules. The policy directs providers to the referenced MNGs on the Provider Resource Center for item-specific billing rules and whether rental, capped rental, or purchase applies. Where Table 9 lists items as no prior authorization required, the MNG still governs documentation and coverage determinations. |
| Prosthetic component type | Rental / Purchase designation |
|---|---|
| Standard prosthetic build components (standard sockets, liners, basic components) | |
| Typically managed as purchase or covered under standard coverage per the applicable MNG and table placement; consult the updated prosthetics MNG and Table 1/Table 4 mappings for current purchase rules and any PA requirements. | |
| Complex or specialty prosthetic components (myoelectric devices, microprocessor knees, specialized sockets, advanced electronics) | |
| May be subject to capped rental or require purchase per the MNG; many complex components remain prior authorization-managed. Follow the prosthetics MNG and table instructions for capped rental vs purchase determinations and any PA requirements. |
Replacement, Repair and Upgrade Rules
Documentation and Submission Requirements
Fax supporting clinical documentation to 857-304-6304 with PA request
Submit supporting clinical documentation with the prior authorization request to Precertification Operations by fax to 857-304-6304.
- Supporting clinical documentation pertinent to the service request must be submitted to the fax number provided for prior authorization (857-304-6304).
Notify Precertification for Table 7; Table 9 may be billed without PA but follow MNGs
Notify Precertification Operations for codes in Table 7 by faxing 857-304-6304; codes listed in Table 9 may be billed without prior authorization but must follow the referenced MNGs for documentation and post-service edit expectations.
- Table 7: notification to Precertification Operations — fax 857-304-6304 (e.g., Acute Hospital at Home).
- Table 9: items (e.g., breast pumps, absorbent products, cardiac event monitors, enteral nutrition) do not require PA but must meet MNG documentation requirements.
Follow the prosthetics MNG for PA documentation requirements
See the relevant Medical Necessity Guideline (MNG) for the documentation required to support prior authorization requests for prosthetic components and complex device elements.
- Prosthetic standard build components were moved to covered lists; myoelectric, microprocessor, and complex components remain managed via PA — consult the prosthetics MNG for required supporting documentation.
Non-covered Home and Community Based Services will be denied
Non-covered Home and Community Based Services are noted in the tables (see Table 1 additions) and will be denied if billed as covered services.
- The policy added Non-Covered Home and Community Based Services – Flexible Benefits for Tufts Health One Care to Table 1 (see approval history and Table 1 for specific codes).
Not Covered and Investigational Services
Procedures designated as investigational in Table 6 are not covered and will be denied when billed as covered services; refer to the Non-Covered Investigational Services MNG for the complete list. Additionally, note that Roctavian was removed from Table 4 because it was removed from the market effective May 1, 2026 and should not be submitted for authorization under Table 4.
Reiterating the investigational status: procedures listed as investigational in Table 6 are considered not covered by the Plan. Providers should consult the Non-Covered Investigational Services MNG for details before submitting claims or authorization requests for codes on Table 6.
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