harvard pilgrim DME Prior Auth Policy Update

Coverage and Prior Authorization Criteria

Table 1 Prior Authorization Criteria

Covered when prior authorization requirements are met and CMS/MassHealth or internal criteria are satisfied

Table 1 prior authorization conditions: Prior authorization must be obtained for the DME, prosthetic items, procedures and services listed in Table 1. Submit inpatient prior authorization requests by fax to 617-673-0705 and outpatient requests by fax to 617-673-0930. Determinations use CMS NCDs/LCDs/Articles, MassHealth DME Provider Manual, and InterQual as cited for individual items.

See individual code lines in Table 1 for specific referenced LCD/NCD/Article

Table 2 Prior Authorization Criteria

Behavioral health procedures require prior authorization through Behavioral Health Department

Table 2 PA conditions: Prior authorization is required for the behavioral health procedure codes listed in Table 2 (for example, Transcranial Magnetic Stimulation codes 90867, 90868, 90869). Submit prior authorization requests to the Behavioral Health Department by fax to 617-673-0930. Medicare Behavioral Health InterQual criteria are used where referenced.

See the Provider Resource Center MNG for detailed Behavioral Health criteria

Table 3 Medicaid-only Prior Authorization Criteria

Medicaid-only covered items require prior authorization per MassHealth criteria

Table 3 PA conditions: Prior authorization is required for Medicaid-only covered procedures, services and DME items listed in Table 3. For DME billed as monthly rentals, prior authorization is required if the cost to purchase the item outright is $1,000 or greater. Submit prior authorizations by fax to 617-673-0930. Coverage decisions will follow MassHealth Guidelines for Medical Necessity Determinations and the MassHealth DME Provider Manual.$1000

Contact Provider Services to identify the Tufts Health Plan SCO care manager when coordinating SCO services

Table 4 Pharmacy Prior Authorization Criteria

Drug and therapy codes listed in Table 4 require prior authorization from Pharmacy Utilization Management

Table 4 PA conditions: Prior authorization is required for the drug and therapy codes managed by the Medical Policy Department and listed in Table 4 (examples include CAR T‑cell therapy codes, specialty J/Q codes, and continuous glucose monitor codes such as A4238 and E2102). Submit prior authorization requests to Pharmacy Utilization Management by fax to 617-673-0956. New‑to‑market drugs are managed according to the Plan's New to Market Drug Medical Necessity Guideline.

Refer to the Provider Resource Center MNGs for specific medical necessity criteria for each drug/therapy

Investigational / Not Covered

Not covered when listed as investigational

Medicare Non-Covered Investigational Services: Procedure codes listed as investigational in Table 6 are considered investigational and are not covered by the Plan. Such services may be denied if billed.

See the Medicare Non-Covered Investigational Services MNG on the Provider Resource Center for specific codes and guidance

Notification Requirements

Notification required for the following categories

Inpatient Admissions Notification: Acute Hospital at Home, Acute Inpatient, LTAC, and SNF/Institutional long‑term care admissions listed in Table 7 require notification to the Inpatient Admission Team via fax to 617-673-0705; concurrent medical necessity review may follow.

LTAC level example: LTAC Level = 120; InterQual and CMS Medicare Benefit Policy Manual are used as referenced

Behavioral Health Notification: Behavioral Health inpatient and 24‑hour levels of care and specified behavioral health services listed in Table 8 require notification to the Behavioral Health Department; inpatient notifications to fax 617-673-0705 and outpatient notifications to fax 617-673-0930. Concurrent review may follow.

InterQual and ASAM referenced for behavioral health criteria

SCO Notification: Specific procedures, services and items for SCO (Tufts Health Plan SCO) listed in Table 9 require prior notification to the SCO care manager (examples: home health care, sleep studies, sleep supplies). Contact Provider Relations at 800-279-9022 to identify the appropriate SCO care manager.

No Prior Authorization

No prior authorization required

No Prior Authorization Required: Procedure codes listed in Table 11 do not require prior authorization from the Plan. These services meet medical necessity criteria though post‑service edits may apply. Examples include intravitreal implants and remote patient monitoring codes listed in Table 11.

The document marks Prior Authorization Required = No in this section

Batteries for power mobility devices are covered without prior authorization. This follows Medicare guidance: batteries for power wheelchairs and related power mobility devices are excluded from the Plan's prior authorization requirements and are billed consistent with Medicare criteria and MassHealth references cited for power mobility devices.

Procedure codes identified as investigational in Table 6 are excluded from coverage. The Plan follows the Medicare Non-Covered Investigational Services Medical Necessity Guideline (MNG); codes listed in Table 6 are considered investigational and are not covered by the Plan.

References to LCDs and LCAs for the Pneumatic Compression Device with Calibrated Gradient Pressure have been removed due to retirement of those documents. Coverage determinations for this device now rely on current internal policy and the remaining cited criteria (CMS and MassHealth) rather than the retired LCD/LCA references.

Services listed as investigational in Table 6 are considered not covered by the Plan. Providers should refer to the Medicare Non-Covered Investigational Services MNG on the Provider Resource Center for the specific investigational code list.

Code Lists and Coding Updates

Table 1 selected procedure codes (sample)mixed

64628	Basivertebral Nerve Ablation (one code listed)
64629	Basivertebral Nerve Ablation (one code listed)
15820	Blepharoplasty and related codes (list continues)
67900	Blepharoplasty and related codes (list continues)

Table 1 selected procedure codes (sample) — source examplemixed

No codes listed

Table 1 DME item codes (sample)HCPCS

E0485	Oral Airway Appliances for Obstructive Sleep Apnea
E0486	Oral Airway Appliances for Obstructive Sleep Apnea
E0748	Osteogenesis Stimulators
E0749	Osteogenesis Stimulators

Table 1 DME item codes (sample) — source exampleHCPCS

No codes listed

Power mobility and pneumatic compression codesmixed

E0652	Pneumatic Compression Device with Calibrated Gradient Pressure
K0010-K0014	Power Wheelchairs (range)
E1230	Power Operated Vehicle

Power mobility and pneumatic compression codes — batteries notemixed

No codes listed

Table 2 Behavioral Health CPT codesCPT

90867	TMS - initial service code
90868	TMS - subsequent
90869	TMS - additional

Table 2 Behavioral Health CPT codes — source exampleCPT

No codes listed

Table 4 drug/therapy codes (sample)HCPCS|J-code

Q2055	Abecma
J9029	Adstiladrin
A4238	CGM - Freestyle (example)
E2102	CGM - Dexcom (example)

Table 4 drug/therapy codes (sample) — source exampleHCPCS|J-code

No codes listed

Table 4 - Specialty Drugs / Procedure CodesHCPCS

Q2055	Abecma
J9029	Adstiladrin
J3490	Amtagvi
Q2058	Aucatzyl
Q2054	Breyanzi
Q2056	Carvykti
J3392	Casgevy
A4238	CGM: Freestyle and Dexcom Products
E2102	CGM: Freestyle and Dexcom Products
J3403	Encelto

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Table 4 - Specialty Drugs / Procedure Codes — source exampleHCPCS

No codes listed

Table 9 - Home Health Care Codes (SCO notification)CPT | HCPCS

G0151	Home Health Care Services
G0152	Home Health Care Services
G0153	Home Health Care Services
G0155	Home Health Care Services
G0156	Home Health Care Services
G0157	Home Health Care Services
G0158	Home Health Care Services
G0162	Home Health Care Services
G0299	Home Health Care Services
G0300	Home Health Care Services

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Table 9 - Home Health Care Codes (SCO notification) — source exampleCPT | HCPCS

No codes listed

Table 9 - Sleep Supplies / PAP therapy equipmentHCPCS

E0601	CPAP
E0470	BiPAP
E0471	BiPAP
A4604	CPAP and BiPAP Supplies
A7027	CPAP and BiPAP Supplies
A7028	CPAP and BiPAP Supplies
A7029	CPAP and BiPAP Supplies
A7030	CPAP and BiPAP Supplies
A7031	CPAP and BiPAP Supplies
A7032	CPAP and BiPAP Supplies

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Table 9 - Sleep Supplies / PAP therapy equipment — source exampleHCPCS

No codes listed

Table 11 - No Prior Authorization Required — source exampleCPT | HCPCSCovered

No codes listed

Table 8 - Behavioral Health Notification CodesCPT | Revenue | HCPCS

114	Behavioral Health revenue code for inpatient
124	Behavioral Health revenue code for inpatient
116	Substance abuse revenue code
126	Substance abuse revenue code
99218	Observation/holding beds
H0017	Residential substance abuse treatment
H2015	Community support program (CSP)
H2016-HH	Community support program (CSP)

Table 8 - Behavioral Health Notification Codes — source exampleCPT | Revenue | HCPCS

No codes listed

Coding updates and hypoglossal nerve stimulatorCPT | HCPCS

E2298	code added to prior authorization under Power Mobility Devices
64582	hypoglossal nerve stimulator code added
64583	hypoglossal nerve stimulator code added
64584	hypoglossal nerve stimulator code added
64568	hypoglossal nerve stimulator code removed
0466T	hypoglossal nerve stimulator code removed
0467T	hypoglossal nerve stimulator code removed
0468T	hypoglossal nerve stimulator code removed

Coding updates and hypoglossal nerve stimulator — source exampleCPT | HCPCS

No codes listed

IMRT and related CPT coding changesCPT | HCPCS

77301	Intensity Modulated Radiation Therapy code removed from prior authorization
77338	Intensity Modulated Radiation Therapy code removed from prior authorization
77385	IMRT code end-dated by CMS and removed from table
77386	IMRT code end-dated by CMS and removed from table
G6015	IMRT code end-dated by CMS and removed from table
G6016	IMRT code end-dated by CMS and removed from table
0421T	Category III CPT updated to code 52597
52597	Updated CPT mapping from 0421T
37500	End-dated CPT code removed effective January 1, 2026

IMRT and related CPT coding changes — source exampleCPT | HCPCS

No codes listed

Upper limb prosthesis HCPCS additions to PAHCPCS

L6028	upper limb prosthesis code added to prior authorization
L6029	upper limb prosthesis code added to prior authorization
L6030	upper limb prosthesis code added to prior authorization
L6031	upper limb prosthesis code added to prior authorization
L6032	upper limb prosthesis code added to prior authorization
L6033	upper limb prosthesis code added to prior authorization
L6037	upper limb prosthesis code added to prior authorization
L6034	upper limb prosthesis code added to prior authorization effective Oct 1, 2025
L6035	upper limb prosthesis code added to prior authorization effective Oct 1, 2025
L6036	upper limb prosthesis code added to prior authorization effective Oct 1, 2025

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Upper limb prosthesis HCPCS additions to PA — source exampleHCPCS

No codes listed

Pharmacy/Drug code additionsHCPCS

J3392

code added for Casgevy

Pharmacy/Drug code additions — source exampleHCPCS

No codes listed

Varicose veins PA removalsCPT

93970	varicose veins code removed from prior authorization
93971	varicose veins code removed from prior authorization

Varicose veins PA removals — source exampleCPT

No codes listed

DME purchase threshold for Medicaid-only

Medicaid-only DME purchase threshold$1000 or greater

ApplicabilityFor DME items billed as monthly rentals, prior authorization is required if purchase cost is $1000 or greater

SubmissionPrior authorizations for Medicaid-only items submitted by fax to 617-673-0930

Provider Requirements and Actionable Rules

Denial Risk

Prior Authorization Required (Condition of Payment)

Supporting clinical documentation pertinent to the service request must be submitted to the FAX numbers listed in the Plan. Failure to submit required documentation and to obtain prior authorization where indicated may result in denial of payment as a condition of payment.

Inpatient prior authorization requests: fax 617-673-0705
Outpatient prior authorization requests: fax 617-673-0930
Drug/therapy prior authorization fax: 617-673-0956

Prior Authorization

Prior Authorization / Notification for Sleep Supplies

Sleep supplies and PAP therapy equipment listed in Table 9 require prior notification to the Tufts Health Plan SCO care manager. Contact Provider Relations at 800-279-9022 to identify the appropriate SCO care manager prior to providing these items.

Medical Necessity References and Guidelines

DME Medical Necessity References

DME and equipment determinations reference CMS NCDs/LCDs and MassHealth DME Provider Manual where applicable

Power mobility medical necessity: Power mobility devices and accessories listed in Table 1 require prior authorization and are evaluated per CMS NCD Mobility Assistive Equipment (280.3), LCD Power Mobility Devices (L33789), related policy articles, and the MassHealth DME Provider Manual. Batteries for power mobility devices are excluded from PA and are covered according to Medicare guidelines.

See Table 1 code lines and MassHealth DME bulletin for rental/purchase guidance

DME Medical Necessity References

Referenced medical necessity guidelines and external criteria

CGM Medical Necessity: Continuous glucose monitoring devices (examples A4238, E2102) reference the LCD 'Glucose Monitors' (L33822) and associated policy article; for non‑diabetes hypoglycemia indications, MassHealth Medical Necessity Guidelines apply. Other referenced devices and services rely on the listed MNGs and CMS NCDs/LCDs as indicated in the tables.

Rental, Purchase and Replacement Rules

Item	Rule / Coverage	Action Required
Medicaid-only DME items billed as monthly rentals
Prior authorization required when the cost to purchase the item outright is $1,000 or greater (applies to DME Medicaid-only covered items with billed charges $1,000 or greater)
Submit prior authorization to Precertification Operations by fax to 617-673-0930; contact Provider Services to identify the Tufts Health Plan SCO care manager before submitting

Item	Rule / Coverage	Action Required
Power mobility device batteries
Covered according to Medicare guidelines; batteries do not require prior authorization
Bill per usual claim submission; no prior authorization required

Item	Rule / Coverage	Action Required / Reference
Power mobility devices and accessories (power wheelchairs, power operated vehicles, components)
Require prior authorization and are evaluated per CMS NCDs/LCDs and MassHealth DME Provider Manual; see referenced Massachusetts DME bulletin for rental/purchase guidance
Follow Precertification Operations PA process; see Massachusetts DME bulletin (Commonwealth of Massachusetts Executive Office of Health and Human Services, Durable Medical Equipment Bulletin 21) for rental vs purchase rules and masshealth references provided in policy

Replacement and Standard Component Guidance

Standard prosthetic build components coverage

Standard prosthetic build components coverage changeStandard prosthetic build components moved to covered (no prior authorization); replacement and rental rules follow existing covered DME policy

Effective timingChange reflected in approval history (services moved to covered) with intent to manage myoelectric and complex components via PA effective February 1, 2026

Impact on PAPA focus shifted to myoelectric and complex prosthetic components; approximately 147 codes removed from PA lists

Documentation and Submission Requirements

Documentation Required

Send clinical documentation with PA requests to Precertification Operations

Submit clinical documentation pertinent to the PA request to the Precertification Operations fax numbers provided; supporting documentation is required with the PA request.

Inpatient PA fax: 617-673-0705; Outpatient PA fax: 617-673-0930.
Include clinical records sufficient to demonstrate medical necessity as referenced in the applicable MNGs.

Note

Notify the appropriate department (Precertification or SCO) as required

Providers must notify the Precertification/Inpatient Admission Team or the SCO care manager for listed DME, inpatient admissions, home health, and sleep supplies prior to or at time of service as specified in Tables 7–10.

Inpatient notification fax: 617-673-0705; Behavioral Health outpatient notifications fax: 617-673-0930.
Contact Provider Relations (800-279-9022) to identify SCO care manager for Table 9 and Table 10 items.

Exclusions and Not Covered Services

Table 6 (referenced) contains procedure codes that the Plan considers investigational and therefore not covered. The document directs providers to the Medicare Non-Covered Investigational Services MNG for details; approval history notes also document related table additions and code management updates.

Procedure codes listed as investigational in Table 6 are not covered by the Plan. Providers should consult the Medicare Non-Covered Investigational Services MNG on the Provider Resource Center for the definitive list and guidance.

The policy no longer relies on LCD and LCA references for the Pneumatic Compression Device with Calibrated Gradient Pressure because those guidance documents have been retired. The removal is documented in the approval history; coverage determinations for this device are now made using the remaining CMS and MassHealth criteria and internal policy references.

Definitions and Reference Tools

Use of InterQual for medical necessity

InterQual as evidence sourcePoint32Health uses InterQual along with the CMS Medicare Benefit Policy Manual as a source of medical evidence to support medical necessity and level-of-care decisions

Use casesApplied for initial and concurrent review processes for inpatient rehab, SNF, LTAC and other level-of-care determinations

Reference locationsListed in Table 1 and Table 7 entries and noted in approval history clarifications

OpenPayer

Prior authorization and notification requirements for DME, procedures, and related services

Coverage and Prior Authorization Criteria

Code Lists and Coding Updates

Provider Requirements and Actionable Rules

Medical Necessity References and Guidelines

Rental, Purchase and Replacement Rules

Replacement and Standard Component Guidance

Documentation and Submission Requirements

Exclusions and Not Covered Services

Definitions and Reference Tools