Modifiedharvard pilgrim health carePolicy N/A

Prior authorization, notification, and no prior authorization requirements for Tufts Medicare Preferred (HMO and PPO)

Governs which services, durable medical equipment (DME), prosthetics, procedures, and drugs require prior authorization or notification for Tufts Medicare Preferred members; applies to providers submitting claims or requesting authorizations.

Policy Summary

Payerharvard pilgrim health care

PolicyPrior authorization, notification, and no prior authorization requirements for Tufts Medicare Preferred (HMO and PPO)

Policy CodePolicy N/A

Change TypeMultiple coding and table additions/updates

Effective DateJun 1, 2026

Next Review DateN/A

Key ActionSubmit prior authorization or vendor notifications (via listed vendor portals or fax numbers) and include supporting clinical documentation with requests.

SourceLink

POLICY UPDATE CHANGES

Table 3 was added and Remote Patient Monitoring was added to notification/no prior authorization tables.

Coding updates for several gene and cell therapy products (e.g., Zynteglo to J3393, Lyfgenia to J3394) and addition of Amtagvi under Table 4.

Hypoglossal nerve stimulator coding was updated (added 64582-64584; removed older codes).

CAR-T administration codes prior authorization was removed; Acute Hospital at Home added as notification.

Added code E2298 to prior authorization under Power Mobility Devices.

Updated Hypoglossal Nerve Stimulator coding: added 64582, 64583, 64584 and removed 64568, 0466T, 0467T, 0468T.

Removed LCD and LCA references from Pneumatic Compression Device with Calibrated Gradient Pressure due to retirement of those references.

Added Removal of Benign Skin Lesion to the no prior authorization list effective January 1, 2025.

Added multiple services (including IMRT, Proton Beam Therapy, Varicose Veins, Transurethral Waterjet Ablation of Prostate, various reconstructive procedures, genetic testing, and others) to prior authorization.

Added numerous HCPCS/L-codes for upper limb prostheses to prior authorization and later removed many codes to change management of standard prosthetic builds effective February 1, 2026.

Moved management of certain spine and interventional pain codes to external vendor (Evolent) and removed specific CPT spine codes from prior authorization effective October 1, 2025.

Added Incontinence Devices (53445), Septoplasty (30520), FoundationOne Liquid CDx (0239U), and multiple lower limb prosthesis codes to prior authorization effective June 1, 2026.

Implantable Neurostimulator - Sacral Nerve Stimulator criteria updated and split into Urinary and Fecal Incontinence; added prior authorization to 64561 and 64581 effective June 1, 2026.

Added E0747 to Osteogenesis Stimulators effective June 1, 2026.

Added code 43249 to Upper Gastrointestinal Endoscopy MNG effective June 1, 2026.

Zevaskyn added to prior authorization effective April 1, 2026; Roctavian removed from prior authorization effective May 1, 2026.

Removed AposTherapy Systems from table 8 effective January 1, 2026.

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Table 1DME, prosthetic items, procedures and services requiring prior authorization

Table 2Procedure codes requiring prior authorization through Behavioral Health

Table 3Drug and therapy codes requiring prior authorization via Pharmacy Utilization Management

No PAPolicy indicates No prior authorization required for some services (Table 9)

NotificationNotification flag set to Yes

MultipleCodes listed across tables (examples)

Coverage, Prior Authorization, and Notification Requirements

Prior authorization groups

Prior authorization required for services listed in the following tables

Table 1: DME, prosthetic items, procedures and services listed in Table 1 require prior authorization through the Precertification Operations Department.see Table 1 codes

Prior authorization requests may be submitted by fax to 617-972-9409

Table 2: Procedures listed in Table 2 require prior authorization through the Behavioral Health Department.see Table 2 codes

Outpatient prior authorization requests may be submitted by fax to 617-972-9409

Table 3: Drug and therapy codes listed in Table 3 require prior authorization from the Pharmacy Utilization Management Department.see Table 3 codes

Prior authorization requests may be submitted by fax to 617-673-0956

Notification Requirements

Notification is required for specified services and concurrent review may apply.

Notification applies to listed services: Notification is required for tables listing DME, prosthetic items, inpatient and post-acute services as specified in Table 6 and Table 7; providers must use specified vendor portals or fax numbers for submission.

See Table 6 and Table 7 for specific codes and submission instructions; inpatient notifications may be submitted by fax to 617-972-9590 and PAP/sleep study notifications must be submitted to eviCore.

Services Not Requiring Prior Authorization

The Plan does not require prior authorization for the services listed in Table 9; these are considered medically necessary when criteria are met but post-service edits may apply.

No prior authorization required: Services and procedure codes listed in Table 9 do not require prior authorization from the Plan; examples include intravitreal implants and corticosteroid inserts, remote patient monitoring, removal of benign skin lesions, and upper gastrointestinal endoscopy (EGD).

Post-service edits may apply.

Vendor-Managed Authorization

Certain services are managed by vendor programs and require prior authorization through those vendors.

Vendor-managed services: PAP devices and sleep studies require prior notification/management through eviCore; interventional pain and spine procedures are managed through Evolent (see vendor site for details); post-acute care and home health require authorization or notification via the specified vendor portals (e.g., Access/Home and Community Care Transitions).

Members included in designated care management agreements may be excluded from some vendor programs; inpatient notifications may be faxed to 617-972-9590.

Medicare Non-Covered Investigational Services

Codes listed as investigational in Table 5 are not covered.

Investigational services not covered: Procedure codes designated investigational in Table 5 are not covered by the Plan and will be denied per the Medicare Non-Covered Investigational Services MNG.

Refer to the Medicare Non-Covered Investigational Services MNG on the Provider Resource Center for details.

Batteries for power mobility devices (power wheelchairs and related mobility assistive equipment) do not require prior authorization and are covered per the document’s referenced Medicare LCD and policy articles. This exception applies to batteries associated with the listed power mobility device HCPCS and K-codes in Table 1; providers may bill per usual coverage rules without submitting a prior authorization request for batteries.

Members who are included in a designated care management agreement with a professional medical group are excluded from certain vendor-managed programs listed in the policy (for example, the Post-Acute Care vendor program). Where the vendor program requires notification or authorization, providers should confirm member enrollment in such care management agreements before submitting requests through the vendor portal.

References to the LCD and LCA for the Pneumatic Compression Device with Calibrated Gradient Pressure were removed from the guideline because those references were retired. Providers should follow the remaining applicable Medicare and internal guidance in this policy for coverage and billing of pneumatic compression devices.

Procedure codes that are classified as investigational in the Medicare Non-Covered Investigational Services Medical Necessity Guideline (MNG) are considered not medically necessary and are not covered by the Plan. Providers should refer to the Plan’s MNG on the Provider Resource Center for the complete list of investigational codes and related rationale.

Codes and Tables (Prior Authorization, Notification, No PA)

Table 1 codes (selected representative extraction)mixedCovered

64628	Basivertebral Nerve Ablation
64629	Basivertebral Nerve Ablation
15820	Blepharoplasty/Brow procedures (one of listed codes)
19318	Breast Reduction
61880	Deep Brain Stimulation procedures (one of listed codes)
63650	Dorsal Column Neurostimulation (one of listed codes)
0037U	FoundationOne CDX
0239U	FoundationOne Liquid CDX
E0764	Functional Neuromuscular
E0770	Functional Neuromuscular

1–10 of 61

1/7

Table 2 codesCPTCovered

96130	Psychological Testing
96131	Psychological Testing
96132	Neuropsychological Testing
96133	Neuropsychological Testing
96136	Psychological/Psychiatric Testing
96137	Psychological/Psychiatric Testing
96138	Neuropsych Assessment
96139	Neuropsych Assessment
96146	Psychological Testing Scoring
90867	TMS (one of listed codes)

1–10 of 12

1/2

Table 3 drug and therapy codes (selected)mixedCovered

Q2055	Abecma
J9029	Adstiladrin
J3490	Amtagvi (misc. drug code)
Q2058	Aucatzyl
Q2054	Breyanzi
Q2056	Carvykti
J3392	Casgevy
Q2042	Kymriah
A4238	CGM: Freestyle and Dexcom Products
E2102	CGM: Freestyle and Dexcom Products

1–10 of 19

1/2

Modified T-Cell Therapies / Gene and Cellular ProductsHCPCS

Q2055	Abecma
J9029	Adstiladrin
J3490	Amtagvi
Q2058	Aucatzyl
Q2054	Breyanzi
Q2056	Carvykti
J3392	Casgevy
Q2042	Kymriah
J3394	Lyfgenia
J3590	Omisigre / Kebilidi (J3590 listed for others)

1–10 of 16

1/2

Therapeutic Continuous Glucose Monitors (CGM)HCPCS

A4238	Freestyle/Dexcom CGM supplies
E2102	Freestyle/Dexcom CGM supplies

PAP devices and suppliesHCPCS

E0601	CPAP
E0470	BiPAP
E0471	BiPAP
A4604	CPAP/BiPAP supplies

PAP vendor-managed notemixed

eviCore

PAP therapy and sleep study prior notification managed via eviCore (providers must submit prior notification to eviCore)

No Prior Authorization codes (examples)mixedCovered

67027	Intravitreal implant procedure
67028	Intravitreal implant procedure
J1096	Intravitreal drug
J7313	Corticosteroid implant
J7311	Corticosteroid implant
J7312	Corticosteroid implant
J7314	Corticosteroid implant
99091	Remote Patient Monitoring
99453	Remote Patient Monitoring
99454	Remote Patient Monitoring

1–10 of 12

1/2

Post-Acute Care / Home Health HCPCSHCPCS

G0151	Home health services
G0152	Home health services
G0153	Home health services
G0155	Home health services
G0156	Home health services
G0157	Home health services
G0158	Home health services
G0159	Home health services
G0160	Home health services
G0161	Home health services

1–10 of 11

1/2

Policy coding changes and PA additions/removalsmixed

E2298	added to prior authorization under Power Mobility Devices
64582	Hypoglossal Nerve Stimulator (added)
64583	Hypoglossal Nerve Stimulator (added)
64584	Hypoglossal Nerve Stimulator (added)
64568	Hypoglossal Nerve Stimulator (removed)
0466T	Hypoglossal Nerve Stimulator (removed)
0467T	Hypoglossal Nerve Stimulator (removed)
0468T	Hypoglossal Nerve Stimulator (removed)
J3392	Casgevy (added Jan 1, 2025)
77301	Intensity Modulated Radiation Therapy (removed from PA retro to Jan 1, 2025)

1–10 of 61

1/7

Power Mobility Batteries prior auth — Batteries do not require prior authorization

Policy statementBatteries for power mobility devices (power wheelchair batteries) are covered and do not require prior authorization.

Coverage referenceCovered according to LCD/Policy Article references cited for power mobility equipment and related accessories.

Related codes/examplesPower wheelchair and accessory groups listed in Table 1 (e.g., K0010 range) — batteries treated as non‑PA items per the policy.

Post-service edits — Post-service edits may apply to services listed as no prior authorization

What Providers Must Do — Prior Authorization and Notification Instructions

Prior Authorization

Pharmacy Utilization Management Prior Authorization

The following drug and therapy codes are managed by the Pharmacy Utilization Management (PUM) Department and require prior authorization from that department. Prior authorization requests for medical-benefit drugs managed by PUM may be submitted by fax to 617-673-0956. This list is illustrative; providers must check the Provider Resource Center for the full, current list and the Plan's New-to-Market Drug Medical Necessity Guideline for drugs without established coverage.

Examples include CAR-T therapies and other specialty agents (see Table 3 for codes such as Q2055, J9029, Q2058, J1411, Q2042, J3401, Q2053, Q2057, Q2041, etc.).
Refer to the Provider Resource Center for the complete, up-to-date list of medical-benefit drugs managed by the pharmacy department and the New-to-Market Drug MNG.

Prior Authorization

Prior Authorization Required for Newly Listed Codes/Services

Several codes and services were added to the Plan's prior authorization requirements effective June 1, 2026 and during prior updates. Providers should review the updated tables and the Approval and Revision History to identify newly listed codes now subject to prior authorization.

Medical Necessity Standards and References

DME medical necessity references

Medicare/CMS criteria references and InterQual are used where specified

CMS/InterQual referenced items: Certain items reference CMS Medicare Benefit Policy Manual chapters, LCDs/NCDs, or InterQual for medical necessity and level-of-care determinations; Point32Health uses InterQual alongside CMS guidance where noted.

See Table 1 entries for specific Medicare criteria references (e.g., Medicare Benefit Policy Manual, LCDs, NCDs) for each item.

Equipment MNG References

Equipment and supplies are subject to Medicare criteria and applicable LCD/NCD references.

CGM criteria: Therapeutic continuous glucose monitors (examples: Freestyle/Dexcom products, codes A4238 and E2102) are governed by the CMS LCD 'Glucose Monitors' (L33822) and related policy articles.

Refer to Table 3 and related LCD/article references for coverage details.

Rental, Purchase, and Prosthetic Management Rules

Item	Coverage rule
Power mobility device batteries
Batteries for power mobility devices do not require prior authorization; they are covered per the referenced LCD/Policy Article for Power Mobility Devices and Wheelchair Options/Accessories.

Item	Coverage action / provider requirement
Power Mobility Devices (including power wheelchairs; E2298 added)
Certain power mobility devices and related HCPCS ranges require prior authorization as listed on the Plan's PA tables; code E2298 was specifically added to prior authorization under Power Mobility Devices. Providers must obtain prior authorization per the PA list before coverage is allowed.

Prosthesis component type	Coverage / purchase rule
Standard (routine) upper limb prosthetic components
Approximately 147 codes associated with standard prosthetic builds were removed from prior authorization and the services moved to covered (effective February 1, 2026); standard components are managed as purchase/covered items rather than requiring PA.
Complex / myoelectric upper limb components
Management remains focused on myoelectric and other complex upper limb prosthetic components which continue to be subject to prior authorization (complex parts remain managed via the PA process).

Submission Requirements and Supporting Documentation

Documentation Required

Include supporting clinical documentation with PA submissions

Submit supporting clinical documentation with prior authorization requests to the fax numbers or portals specified for the managing department; documentation is required to demonstrate medical necessity.

The policy explicitly requires supporting clinical documentation be submitted with PA requests.
Follow the department-specific submission instructions (e.g., 617-972-9409 for Precert Operations, 617-673-0956 for Pharmacy UM).

Billing Rule

Use vendor-specific portals and fax routes for notifications and authorizations

Use the vendor-specific submission channels listed in the policy for vendor-managed programs; inpatient notifications may be faxed to 617-972-9590 and post-acute authorizations use the Access/Home and Community Care Transitions portal as directed.

Investigational and Non-Covered Services

Table 5 lists procedure codes the Plan deems investigational and therefore not covered. Refer to Table 5 and the Medicare Non-Covered Investigational Services MNG on the Provider Resource Center for the specific procedure codes and details.

Equipment or procedures designated investigational per Table 5 and the associated Medicare Non-Covered Investigational Services MNG on the Provider Resource Center are not covered. Note that specific items and vendor-managed listings have been revised in approval history; for example, AposTherapy Systems were removed from the management list effective January 1, 2026.

The removal of AposTherapy Systems from the policy’s vendor/management tables is reflected in the approval history and became effective January 1, 2026. Equipment or procedures listed as investigational in Table 5 and associated MNGs remain not covered; the AposTherapy System removal represents a specific, dated change to those management tables.

Policy Basis and Scope

The Plan uses CMS and MassHealth guidance (including NCDs, LCDs, LCAs and Medicare manuals) and, where applicable, InterQual and internally developed medical necessity guidelines to inform coverage determinations for members eligible for both products. Providers should apply the referenced CMS guidance and applicable Medicare manuals when documenting medical necessity for Dual Product Eligible members.

Key Terms and Vendor Programs

InterQual used as a source of medical evidence for level of care decisions — definition note

DefinitionInterQual is used by the Plan as a source of medical evidence to support medical necessity and level‑of‑care decisions in conjunction with the CMS Medicare Benefit Policy Manual.

Scope of useApplied for initial medical necessity and level of care determinations for inpatient, post‑acute, and specified services as noted in Table 1 and Table 4.

Operational implicationProviders may submit InterQual‑based clinical findings as part of supporting documentation for authorization and notification requests.

Vendor Managed Program — definition and use for certain device programs

DefinitionVendor Managed Program: a third‑party vendor (for example, eviCore or Evolent) that performs prior notification/authorization or management for specified services on behalf of the Plan.

Policy Summary

Payerharvard pilgrim health care

PolicyPrior authorization, notification, and no prior authorization requirements for Tufts Medicare Preferred (HMO and PPO)

Policy CodePolicy N/A

Change TypeMultiple coding and table additions/updates

Effective DateJun 1, 2026

Next Review DateN/A

Key ActionSubmit prior authorization or vendor notifications (via listed vendor portals or fax numbers) and include supporting clinical documentation with requests.

SourceLink

On This Page

Policy statementServices listed in the Plan's No Prior Authorization table (Table 9) remain subject to post‑service edits; no prior authorization is required but claims may be reviewed after service submission.

Examples affectedIntravitreal implants, remote patient monitoring, removal of benign skin lesions, upper GI endoscopy (Table 9 examples).

Operational noteProviders should ensure documentation supports medical necessity at time of service because post‑service edits may result in claim adjustments or denials.

no_prior_authorization_effective_date

Effective dateJanuary 1, 2025

ContextDate associated with adding Removal of Benign Skin Lesion to the no prior authorization list (Table 9).

ImpactServices moved to no prior authorization effective this date remain subject to post‑service review per policy language.

Notable recent additions effective June 1, 2026: Incontinence devices (53445); Septoplasty (30520); FoundationOne Liquid CDx (0239U); Lower limb prostheses (L5827, L5828, L5856, L5857, L5858, L5980, L5981, L5987, L5973); Implantable neurostimulator sacral nerve simulator codes 64561 and 64581; Osteogenesis stimulator E0747; Upper GI endoscopy code 43249.
Other additions and removals are documented in the Approval and Revision History — confirm code status and effective dates before rendering or billing services.

Denial Risk

Authorization and Payment Condition

Failure to ensure that any required prior authorization or notification has been obtained may affect claim payment. Obtaining the required prior authorization (or submitting required notifications) is a condition of payment; claims for services performed without required authorization may be denied.

Providers who are not the party obtaining prior authorization are still responsible for confirming authorization was secured prior to performing the service.
If notification is required for continued services, updated clinical information may be requested to qualify for ongoing coverage.

Denial Risk

Investigational / Non-Covered Services

Procedure codes listed as investigational are not covered by the Plan and will be denied per the Medicare Non-Covered Investigational Services Medical Necessity Guideline. Providers should not submit claims for investigational services expecting coverage.

See the Medicare Non-Covered Investigational Services MNG on the Provider Resource Center for details and the specific codes considered investigational.
If a service is classified investigational, use the MNG to confirm non-coverage before scheduling or billing.

Documentation Required

Submission Routes and Contact

Submission routes and contact information for prior authorization and notifications are shown below. Use the specified fax numbers, vendor portals, or department channels for each table/vendor to avoid delays.

Precertification Operations prior authorization (Table 1, Table 2 outpatient behavioral health): fax to 617-972-9409.
Pharmacy Utilization Management prior authorization (Table 3): fax to 617-673-0956.
Inpatient notification requests (Table 6): fax to 617-972-9590.
Vendor-managed programs (e.g., eviCore for PAP devices and sleep studies): providers must submit prior notification via the vendor portal or by calling the vendor (eviCore: 888-511-0401).
For vendor-managed post-acute care and other vendor programs, follow the vendor-specific portal/contact instructions in the applicable table (see Table 8 and provider portals).

PAP criteria: Positive airway pressure (CPAP/BiPAP) devices and supplies are governed by NCDs and LCDs for respiratory assist devices and PAP devices; sleep studies and PAP therapy require prior notification to eviCore.

See Table 4 for PAP device and sleep study codes and submission instructions.

Sacral nerve stimulator criteria update

Updates indicate additions to prior authorization and splitting of sacral neurostimulator criteria into urinary and fecal indications.

Sacral Nerve Stimulator criteria split: Implantable neurostimulator — sacral nerve stimulator criteria have been updated and split into Urinary Incontinence and Fecal Incontinence indications; prior authorization was added to codes 64561 and 64581 effective June 1, 2026.

See Approval and Revision History for effective dates and details.

eviCore is required for PAP/sleep study notifications; Access/Home and Community Care Transitions portal is used for post-acute care authorization.
Confirm the correct submission route for the service/vendor before initiating the request.

Documentation Required

When specified, include InterQual documentation to support medical necessity

InterQual may be used to support medical necessity as noted in table clarifications; include InterQual rationale when the table or MNG specifies its use for level-of-care or medical necessity determinations.

A clarifying line was added to Table 1 and Table 6 indicating Point32Health uses InterQual alongside CMS manuals.

eviCore manages sleep diagnostics and PAP device notifications; Evolent manages interventional pain and spine procedure authorizations; Access/Home and Community Care Transitions manage post‑acute care notifications.

Provider actionProviders must submit prior notification/authorization requests through the vendor's portal or contact channels (e.g., eviCore website or phone 888‑511‑0401; inpatient fax 617‑972‑9590 for vendor notifications where applicable).