As you likely know, National Imaging Associates, Inc. (NIA) reviews medical necessity and manages prior authorizations on behalf of Point32Health’s Harvard Pilgrim Health Care Commercial and StrideSM (HMO)(HMO-POS) and Tufts Health Plan Commercial and Public Plans products for certain procedures:
- Outpatient cardiac, diagnostic imaging/radiology, and interventional pain management
- Inpatient and outpatient musculoskeletal services — with the exception of the following product exclusions:
- Tufts Health Public Plans products are excluded from NIA’s cardiac program
Tufts Health Unify is included only in NIA’s high-tech imaging program (excluded from the cardiac, musculoskeletal, and joint surgery programs) - Tufts Health Plan CareLink members and members on the Cigna network are excluded from the NIA program, and
- Tufts Health Plan excludes members under 18 from NIA’s cardiac program
- Tufts Health Public Plans products are excluded from NIA’s cardiac program
The chart below identifies code updates to Point32Health and NIA’s authorization and medical necessity review program, which are effective June 1, 2023 and are intended to align coverage and criteria for the Harvard Pilgrim and Tufts Health Plan products included in the program. Please refer to the NIA information and resources in the vendor programs sections of the Harvard Pilgrim and Tufts Health Plan websites for the updated utilization review/code matrices for the applicable services.
NIA code updates effective June 1, 2023
| Code(s) | Service(s) | Products Affected | Summary |
| 93356 | Transthoracic Echocardiography, Stress Echocardiography | Harvard Pilgrim Commercial and Stride | Code will no longer be covered for Harvard Pilgrim plans. |
| G0219 | Tumor Imaging, PET- Melanoma | Harvard Pilgrim Commercial and Stride | Prior authorization will no longer be required for Harvard Pilgrim. |
| G0235 | Tumor Imaging, PET – Any Site (unlisted PET) | Harvard Pilgrim Commercial and Stride | Prior authorization will no longer be required for Harvard Pilgrim. |
| G0252 | Tumor Imaging, PET- Breast Cancer initial DX | Harvard Pilgrim Commercial and Stride | Prior authorization will no longer be required for Harvard Pilgrim. |
| 78429, 78434, 78430, 78431, 78432, 78433 | Heart PET Scan with CT for Attenuation | Tufts Health Plan Commercial, Tufts Health Public Plans | Code will require prior authorization through NIA for Tufts Health Plan. |
| 74261, 74262 | CT Virtual Colonoscopy for Diagnostic | All applicable Point32Health products | Prior authorization will continue to be required, but will be reviewed using standard NIA criteria, as opposed to customized. |
| 78434 | Heart PET Scan | Tufts Health Plan Commercial, Tufts Health Public Plans | Code will be covered with prior authorization for Tufts Health Plan. |
| 70486, 70487, 70488, 76380 | CT Maxillofacial/Sinus | Tufts Health Plan Commercial, Tufts Health Public | Plans Prior authorization will continue to be required for all applicable Point32Health products, but will be reviewed using standard NIA criteria, as opposed to customized. |
| 75571, S8092 | Coronary artery CAC score, heart scan, ultrafast CT heart, electron beam CT | Harvard Pilgrim Commercial and Stride | Code will no longer be covered for Harvard Pilgrim plans. |
| 74712, 74713 | Fetal MRI | Harvard Pilgrim Commercial and Stride | Prior authorization will be required through NIA for Harvard Pilgrim. |
| 27279 | Sacroiliac joint arthrodesis, percutaneous SIJ Fusion | Harvard Pilgrim Commercial and Stride | Prior authorization will be required through NIA for Harvard Pilgrim. |
| 22857, 22862, 22865 | Lumbar Artificial Disc Replacement – Single Level | All applicable Point32Health products | Will be covered with prior authorization for Harvard Pilgrim and Tufts Health Plan. |
| 22860, 0164T, 0165T | Lumbar Artificial Disc Replacement – Multiple Levels | All applicable Point32Health products | Will be covered with prior authorization for Harvard Pilgrim and Tufts Health Plan. |
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