Diabetes Management Devices(Eff. beginning 1.1.24) Form

Harvard Pilgrim | TUFTS Health Care

Medical Necessity Guidelines: Diabetes Management Devices
Effective: January 1, 2024

Prior Authorization Required

• If REQUIRED, submit supporting clinical documentation pertinent to service request to the FAX numbers below

Yes ☒ No ☐

Notification Required

IF REQUIRED, concurrent review may apply
Yes ☐ No ☒

Applies to:

• Commercial Products
  • Harvard Pilgrim Health Care Commercial products; 800-232-0816
  • Tufts Health Plan Commercial products; 617-972-9409
• CareLinkSM – Refer to CareLink Procedures, Services and Items Requiring Prior Authorization
• Public Plans Products
  • Tufts Health Direct – A Massachusetts Qualified Health Plan (QHP) (a commercial product); 888-415-9055
  • Tufts Health Together – MassHealth MCO Plan and Accountable Care Partnership Plans; 888-415-9055
  • Tufts Health RITogether – A Rhode Island Medicaid Plan; 857-304-6404
  • Tufts Health One Care Plan – A dual-eligible product; 857-304-6304
• Senior Products
  • Harvard Pilgrim Health Care Stride Medicare Advantage; 888-609-0692
  • Tufts Health Plan Senior Care Options (SCO), (a dual-eligible product); 617-673-0965
  • Tufts Medicare Preferred HMO, (a Medicare Advantage product); 617-673-0965
  • Tufts Medicare Preferred PPO, (a Medicare Advantage product); 617-673-0965

Note: While you may not be the provider responsible for obtaining prior authorization or notifying Point32Health, as a condition of payment you will need to ensure that any necessary prior authorization has been obtained and/or Point32Health has received proper notification. If notification is required, providers may additionally be required to provide updated clinical information to qualify for continued service.

Clinical Guideline Coverage Criteria

Harvard Pilgrim Health Care uses guidance from the Centers for Medicare and Medicaid Services (CMS) for coverage determinations for its Medicare Advantage plan members. CMS National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), Local Coverage Articles (LCAs) and documentation included in the Medicare manuals are the basis for coverage determinations where available. For Harvard Pilgrim Health Care Medicare Advantage plan members, the following criteria is used: LCD - Glucose Monitors (L33822) (cms.gov) and Article - Billing and