Currentharvard pilgrim health carePolicy N/A

Ankle Arthroscopy

Defines prior authorization requirement and use of InterQual SmartSheets for ankle and subtalar arthroscopy procedures, lists CPT/HCPCS codes requiring authorization, and provides administrative guidance for Harvard Pilgrim and Tufts Health Plan products. Applies to commercial and certain public plan products; policy references InterQual subsets for medical necessity decisions.

Policy Summary

Payerharvard pilgrim health care

PolicyAnkle Arthroscopy

Policy CodePolicy N/A

Change TypeAdministrative / Renewal

Effective DateJan 1, 2026

Next Review Date

Key ActionObtain prior authorization using the InterQual 'Arthroscopy, Surgical, Ankle' SmartSheet and submit supporting clinical documentation via HPHConnect Clinical Upload or secure fax for Harvard Pilgrim, or via Tufts Provider Website/InterQual SmartSheets for Tufts products.

SourceLink

POLICY UPDATE CHANGES

Reviewed by MPAC and renewed without changes effective January 1, 2026; December 2025 administrative updates effective January 1, 2026.

11CPT Codes Requiring Prior Authorization

InterQualRequired Clinical Decision Support Tool

Harvard Pilgrim / TuftsCommercial Products Covered

Coverage Summary

Coverage stance: covered_with_criteria. Subject: Ankle Arthroscopy Prior Authorization and Medical Necessity Guideline.

Scope summary: Defines prior authorization requirement and use of InterQual SmartSheets for ankle and subtalar arthroscopy procedures, lists CPT/HCPCS codes requiring authorization (see CPT Codes Requiring Prior Authorization), and provides administrative guidance for Harvard Pilgrim and Tufts Health Plan products. Products covered include Harvard Pilgrim and Tufts commercial products (and certain public plan products).

Products covered (from stats/scope): Harvard Pilgrim / Tufts commercial products with specified contact/portal routes for authorization and SmartSheet access.

Effective/last review dates: Effective January 1, 2026; Last review November 19, 2025 (policy history notes initial MPAC November 21, 2024 and InterQual upgrade July 1, 2025).

Prior authorization note: Use of the InterQual SmartSheet 'Arthroscopy, Surgical, Ankle' is required to obtain prior authorization for the listed ankle and subtalar arthroscopy CPT/HCPCS codes; SmartSheets are required for Tufts and InterQual/HPHConnect processes apply for Harvard Pilgrim.

Medical Necessity & Authorization Criteria

Prior Authorization Requirement and Clinical Guideline

The Plan requires use of the InterQual Subset 'Arthroscopy, Surgical, Ankle' to obtain prior authorization for ankle arthroscopy procedures.

Prior Authorization and Clinical Guideline

Prior Authorization Requirement: Prior authorization is required to obtain coverage/approval for the listed ankle and subtalar arthroscopy CPT/HCPCS codes.
If required, submit supporting clinical documentation pertinent to the service request to the designated fax/portal per product instructions.
Clinical Guideline Use: The Plan requires the use of the InterQual Subset 'Arthroscopy, Surgical, Ankle' (InterQual SmartSheet) to obtain prior authorization and determine medical necessity.
For Harvard Pilgrim: request authorization and complete the automated authorization questionnaire via HPHConnect; submit clinical notes via HPHConnect Clinical Upload or secure fax (800-232-0816). For Tufts Health Plan: Tufts requires use of current InterQual SmartSheets via the Provider Website/PA process. Providers may view/print criteria via HPHConnect or Provider Website.

Codes Requiring Prior Authorization: Specific CPT/HCPCS codes for ankle and subtalar arthroscopy require prior authorization.

See policy code list for codes such as 29891, 29892, 29894-29899, 29904-29907.

CPT/HCPCS Codes

CPT/HCPCS Codes Requiring Prior AuthorizationCPTCovered

29891	Arthroscopy, ankle, surgical, excision of osteochondral defect of talus and/or tibia, including drilling of the defect.
29892	Arthroscopically aided repair of large osteochondritis dissecans lesion, talar dome fracture, or tibial plafond fracture, with or without internal fixation (includes arthroscopy).
29894	Arthroscopy, ankle (tibiotalar and fibulotalar joints), surgical; with removal of loose body or foreign body.
29895	Arthroscopy, ankle (tibiotalar and fibulotalar joints), surgical; synovectomy, partial.
29897	Arthroscopy, ankle (tibiotalar and fibulotalar joints), surgical; debridement, limited.
29898	Arthroscopy, ankle (tibiotalar and fibulotalar joints), surgical; debridement, extensive.
29899	Arthroscopy, ankle (tibiotalar and fibulotalar joints), surgical; with ankle arthrodesis.
29904	Arthroscopy, subtalar joint, surgical; with removal of loose body or foreign body.
29905	Arthroscopy, subtalar joint, surgical; with synovectomy.
29906	Arthroscopy, subtalar joint, surgical; with debridement.

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Actions for Providers (Prior Authorization & Documentation)

Prior Authorization

Prior Authorization Required for Listed CPT Codes

Obtain prior authorization using the InterQual SmartSheet 'Arthroscopy, Surgical, Ankle' for the listed ankle and subtalar arthroscopy CPT/HCPCS codes. Submit the authorization request and any required clinical documentation via HPHConnect Clinical Upload or secure fax for Harvard Pilgrim members, or via the Tufts Provider Website/InterQual SmartSheets for Tufts products.

29891
29892
29894
29895
29897
29898
29899
29904
29905
29906
29907

Documentation Required

Clinical Documentation Submission

Submit pertinent clinical notes and written documentation as part of the authorization request to support medical necessity review.

Failure to provide required documentation may affect medical necessity review and payment.

Billing Rule

Prior Authorization Contact Points

Contact portals and submission methods differ by product. For Harvard Pilgrim, request authorization via HPHConnect and submit clinical notes via HPHConnect Clinical Upload or secure fax (800-232-0816). For Tufts, use the Provider Website to access InterQual SmartSheets as part of the prior authorization process and follow Provider Services registration/instructions.

Background and Definitions

Medical Necessity Guidelines specify coverage decisions using InterQual criteria, current literature review, and consultation with practicing physician experts; they are used together with the member's benefit document and clinician judgment to determine coverage on a case-by-case basis.

For certain Medicaid pediatric members (Tufts Health Together), services may be covered beyond these guidelines under EPSDT (Early and Periodic Screening, Diagnostic and Treatment) benefits with prior authorization.

InterQual criteria and tools are used operationally to determine medical necessity and authorization; Harvard Pilgrim may use customized InterQual tools accessible via HPHConnect, and Tufts requires current InterQual SmartSheets as part of the prior authorization process.

InterQual SmartSheet: a proprietary clinical decision support subset (the current InterQual SmartSheet 'Arthroscopy, Surgical, Ankle') used to determine medical necessity and to obtain prior authorization for the specified ankle and subtalar arthroscopy procedures.

Revision History

2025-03-01original_effective

Policy originally effective March 1, 2025 after initial MPAC on November 21, 2024.

2025-07-01interqual_upgrade

InterQual upgrade effective July 1, 2025 (MPAC reviewed May 21, 2025).

2026-01-01review_renewedLatest

Reviewed by MPAC and renewed without changes effective January 1, 2026 (MPAC review November 19, 2025).

2026-01-01administrative_update

December 2025 administrative updates effective January 1, 2026.