Prior authorization, notification, and no prior authorization requirements for Tufts Medicare Preferred (HMO and PPO)
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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.
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.
Coverage, Prior Authorization, and Notification Requirements
Prior authorization groups
Prior authorization required for services listed in the following tables
Prior authorization requests may be submitted by fax to 617-972-9409
Outpatient prior authorization requests may be submitted by fax to 617-972-9409
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.
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.
Post-service edits may apply.
Vendor-Managed Authorization
Certain services are managed by vendor programs and require prior authorization through those vendors.
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.
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)
| 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 |
| 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) |
| eviCore | PAP therapy and sleep study prior notification managed via eviCore (providers must submit prior notification to eviCore) |
| 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 |
| 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 |
| 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) |
What Providers Must Do — Prior Authorization and Notification Instructions
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 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.
- 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.
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.
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.
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).
Medical Necessity Standards and References
DME medical necessity references
Medicare/CMS criteria references and InterQual are used where specified
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.
Refer to Table 3 and related LCD/article references for coverage details.
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.
See Approval and Revision History for effective dates and 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
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).
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.
- 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.
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.
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
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