Blepharoplasty, Upper/Lower Eyelid, and Brow and/or Eyelid Ptosis Repair(Eff. beginning 1.1.24) Form

TUFTS Health Plan Harvard Pilgrim HealthCare

Medical Necessity Guidelines: Blepharoplasty, Upper/Lower Eyelid, and Brow and/or Eyelid Ptosis Repair
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 – A dual-eligible product; 857-304-6304 ☒

Senior Products

• Harvard Pilgrim Health Care Stride Medicare Advantage; 866-874-0857 ☐
• 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.

For Harvard Pilgrim Health Care Members:

This policy utilizes InterQual® criteria and/or tools, which Harvard Pilgrim may have customized. You may request authorization and complete the automated authorization questionnaire via HPHConnect at www.harvardpilgrim.org/providerportal. In some cases, clinical documentation may be required to complete a medical necessity review. Please submit required documentation as follows:

• Clinical notes/written documentation – via HPHConnect Clinical Upload or secure fax (800-232-0816)
• Providers may view and print the medical necessity criteria and questionnaire via HPHConnect for providers (Select Researched and the InterQual® link) or contact the commercial Provider Service Center at 800-708-4414. (To register for HPHConnect, follow the instructions here).
• Members may access materials by logging into their online account (visit www.harvardpilgrim.org, click on Member Login, then Plan Details, Prior Authorization for Care, and the link to clinical criteria) or by calling Member Services at 888-333-4742.

For Tufts Health Plan Members:

To obtain InterQual® SmartSheetsTM:

• Tufts Health Plan Commercial Plan products: If you are a registered Tufts Health Plan provider click here to access the Provider Website. If you are not a Tufts Health Plan provider, please click on the Provider Log-in and follow instructions to register on the Provider website or call Provider Services at 888-884-2404
• Tufts Health Public Plans products: InterQual® SmartSheet(s) available as part of the prior authorization process

2110020Blepharoplasty, Upper/Lower Eyelid, and Brow and/or Eyelid Ptosis Repair1

Tufts Health Plan requires the use of current InterQual® SmartSheet(s) to obtain prior authorization. In order to obtain prior authorization for procedure(s), choose the appropriate InterQual® SmartSheet(s) listed below. The completed SmartSheet(s) must be sent to the applicable fax number indicated above, according to Plan

Clinical Guideline Coverage Criteria

The Plan uses guidance from the Centers for Medicare and Medicaid Services (CMS) and MassHealth for coverage determinations for its Dual Product Eligible plan Members.

CMS National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), Local Coverage Articles (LCAs) and documentation included in the Medicare manuals and MassHealth Medical Necessity Determinations are the basis for coverage determinations where available. For Tuft’s Health One Care plan Members, the following criteria is used: LCD - Blepharoplasty, Blepharoptosis and Brow Lift (L34528) (cms.gov) and Article - Billing and