CurrentMass General Brigham Health PlanPolicy N/A

Prior Authorization Lists for MED ADV and MCR ADV

Lists specific HCPCS/CPT codes that require prior authorization for Mass General Brigham Health Plan Medicare Advantage (MED ADV) and codes that do not require prior authorization for Medicare Advantage (MCR ADV); affects providers submitting claims to the plan.

Policy Summary

PayerMass General Brigham Health Plan

PolicyPrior Authorization Lists for MED ADV and MCR ADV

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization for listed MED ADV codes before billing; MCR ADV codes listed do not require prior authorization unless noted as New to Market.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~150+listed codes across prior auth required and not required sections

2distinct coverage categories

presentnew-to-market flag

Prior Authorization and No-Prior-Auth Code Lists

Prior authorization required (MED ADV)

Codes that require prior authorization under MED ADV.

Policy Summary

PayerMass General Brigham Health Plan

PolicyPrior Authorization Lists for MED ADV and MCR ADV

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization for listed MED ADV codes before billing; MCR ADV codes listed do not require prior authorization unless noted as New to Market.

SourceLink

On This Page

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Providers must obtain prior authorization for the codes listed under MED ADV when billing Mass General Brigham Health Plan Medicare Advantage (MED ADV).

Code list

A9506 — Graphite crucible for preparation of technetium tc 99m-labeled carbon aerosol, one crucible.
C1605 — Pacemaker, leadless, dual chamber (right atrial and right ventricular implantable components), rate-responsive, including all necessary components for implantation.
C1606 — Adapter, single use (disposable), for attaching ultrasound system to upper gastrointestinal endoscope.
C9901 — Endoscopic defect closure within the entire gastrointestinal tract, including upper endoscopy or colonoscopy, with all system and tissue anchoring components.
J7171 — Injection, adamts13, recombinant-krhn, 10 IU.
J3247 — Injection, secukinumab, intravenous, 1 mg.
J3263 — Injection, toripalimab-tpzi, 1 mg.
J3394 — Injection, lovotibeglogene autotemcel, per treatment.
J2267 — Injection, mirikizumab-mrkz, 1 mg.
J3393 — Injection, betibeglogene autotemcel, per treatment.
Q4331 — Axolotl graft, per square centimeter.
Q4332 — Axolotl dualgraft, per square centimeter.
OO20M — Oncology (central nervous system), analysis of 30000 DNA methylation loci by methylation array, diagnostic algorithm reported as probability of matching a reference tumor subclass.
0450U — Oncology (multiple myeloma), liquid chromatography with tandem mass spectrometry (LC-MS/MS), monoclonal paraprotein sequencing analysis, serum, results reported as baseline presence or absence of detectable clonotypic peptides.
0451U — Oncology (multiple myeloma), LC-MS/MS, peptide ion quantification.

ref

No prior authorization required (MCR ADV)

Codes that do not require prior authorization under MCR ADV.

The following codes are listed as not requiring prior authorization when billing Medicare Advantage (MCR ADV).

Code list

90637 — Influenza virus vaccine, quadrivalent (qIRV), mRNA; 30 mcg/0.5 mL dosage, for intramuscular use.
90638 — Influenza virus vaccine, quadrivalent (qIRV), mRNA; 60 mcg/0.5 mL dosage, for intramuscular use.
90684 — Pneumococcal conjugate vaccine, 21 valent (PCV21); for intramuscular use.
GO521 — Management of new patient-caregiver dyad with dementia, high complexity, for use in CMMI model.
60522 — Management of a new patient with dementia, low complexity, for use in CMMI model.
60523 — Management of a new patient with dementia, moderate to high complexity, for use in CMMI model.
60524 — Management of established patient-caregiver dyad with dementia, low complexity, for use in CMMI model.

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New to Market — MCR ADV

New-to-market items flagged for MCR ADV; these items are not covered for Medicare Advantage unless prior authorized.

New-to-market codes listed below are not covered for MCR ADV unless prior authorization is obtained.

New-to-market code list

J9361 — Injection, efbemalenograstim alfa-vUxw, 0.5 mg.
Q5137 — Injection, ustekinumab-auub (Wezlana), biosimilar, SC, 1 mg.
Q5138 — Injection, ustekinumab-auub (Wezlana), biosimilar, IV, 1 mg.

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Selected Code Tables

Selected MED ADV prior auth codes (partial list)CPTCovered

A9506	Graphite crucible for preparation of technetium tc 99m-labeled carbon aerosol, one crucible.
C1605	Pacemaker, leadless, dual chamber (right atrial and right ventricular implantable components) , rate- responsive, including all necessary components for implantation.
C1606	Adapter, single use (i.e , disposable) , for attaching ultrasound system to upper gastrointestinal endoscope.
C9901	Endoscopic defect closure within the entire gastrointestinal tract, including upper endoscopy (including diagnostic, if performed) or colonoscopy (including diagnostic, if performed), with all system and tissue anchoring components.

Selected MCR ADV no prior auth vaccines (partial list)CPTCovered

90637	Influenza virus vaccine, quadrivalent (qIRV), mRNA; 30 mcg/o.5 mL dosage, for intramuscular use.
90638	Influenza virus vaccine, quadrivalent (qIRV), mRNA; 60 mcg/o.5 mL dosage, for intramuscular use.
90684	Pneumococcal conjugate vaccine, 21 valent (PCV21); for intramuscular use.

What Providers Must Do

Prior Authorization

Prior Authorization Required (MED ADV)

Prior authorization is required for the following MED ADV items and codes. Submit prior authorization requests per Mass General Brigham Health Plan procedures to avoid denials.

A9506 — Graphite crucible for preparation of technetium tc 99m‑labeled carbon aerosol, one crucible
C1605 — Pacemaker, leadless, dual chamber, rate‑responsive, including all necessary components for implantation
C1606 — Adapter, single use for attaching ultrasound system to upper gastrointestinal endoscope
C9901 — Endoscopic defect closure within the entire gastrointestinal tract, includes system and tissue anchoring components
J7171 — Injection, adamts13, recombinant‑krhn, 10 IU
J3247 — Injection, secukinumab, intravenous, 1 mg
J3263 — Injection, toripalimab‑tpzi, 1 mg
J3394 — Injection, lovotibeglogene autotemcel, per treatment
J2267 — Injection, mirikizumab‑mrkz, 1 mg
J3393 — Injection, betibeglogene autotemcel, per treatment
Q4331 — Axolotl graft, per square centimeter
Q4332 — Axolotl dualgraft, per square centimeter
OO20M — Oncology (CNS), methylation array analysis of 30,000 DNA loci, diagnostic algorithm reported
0450U — Oncology (multiple myeloma), LC‑MS/MS monoclonal paraprotein sequencing analysis, serum
0451U — Oncology (multiple myeloma), LC‑MS/MS peptide ion quantification

Note

No Prior Authorization Required (MCR ADV)

The following MCR ADV codes do not require prior authorization. Providers may bill these codes without submitting a prior authorization request.

90637 — Influenza vaccine, quadrivalent, mRNA, 30 mcg/0.5 mL, IM
90638 — Influenza vaccine, quadrivalent, mRNA, 60 mcg/0.5 mL, IM
90684 — Pneumococcal conjugate vaccine, 21‑valent (PCV21), IM
60522 — Management of a new patient with dementia, low complexity (CMMI model)
60523 — Management of a new patient with dementia, moderate to high complexity (CMMI model)
60524 — Management of established patient‑caregiver dyad with dementia, low complexity (CMMI model)
GO521 — Management of new patient‑caregiver dyad with dementia, high complexity (CMMI model)

Prior Authorization

New to Market (MCR ADV) — Prior Authorization Required

New‑to‑market MCR ADV products are not covered unless a prior authorization is obtained. Obtain prior authorization for these items to determine coverage eligibility before providing service.

J9361 — Injection, efbemalenograstim alfa‑vUxw, 0.5 mg
Q5137 — Injection, ustekinumab‑auub (Wezlana), biosimilar, SC, 1 mg
Q5138 — Injection, ustekinumab‑auub (Wezlana), biosimilar, IV, 1 mg

Key Term Clarifications

inv-09: Medicare Advantage (MED ADV) — Prior authorization required

DefinitionMedicare Advantage (MED ADV) — codes listed under this heading require prior authorization.

ActionProviders must obtain prior authorization for the specific HCPCS/CPT/other codes listed under MED ADV before billing.

Example codes (partial)A9506; C1605; C1606; C9901; J7171; J3247; J3263; J3394

Laboratory/Assay examplesOO20M; 0450U; 0451U; (oncology/molecular assay codes listed require prior authorization)

Device examplesQ4331; Q4332 (graft products require prior authorization)

inv-10: Medicare Advantage (MCR ADV) — No prior authorization required (unless New to Market)

DefinitionMedicare Advantage (MCR ADV) — codes listed under this heading do not require prior authorization unless specifically noted as New to Market.

ActionDo not submit prior authorization for the listed MCR ADV codes unless the code appears in the New to Market section.

Example no‑prior‑auth vaccine codes (partial)90637; 90638; 90684

New to Market exceptionCodes listed in the New to Market section (e.g., J9361; Q5137; Q5138) are not covered for MCR ADV unless prior authorized.

Clinical noteIf a code is not in the MCR ADV list and is designated New to Market, obtain prior authorization prior to billing for MCR ADV members.