Back to Insights and Updates for ProvidersApril 2023

Radiation oncology coverage updates

Harvard Pilgrim Health Care Commercial  |  Harvard Pilgrim Stride (HMO) Medicare Advantage  |  Tufts Health Plan Commercial  |  Tufts Health Public Plans

As we communicated in the February issue of Insights and Updates for Providers, Harvard Pilgrim Health Care is no longer using OncoHealth for radiation oncology medical management for Commercial and StrideSM (HMO)/(HMO-POS) Medicare Advantage members.

The previous article outlines specific prior authorization changes for Harvard Pilgrim plans, as well as some changes being implemented for Tufts Health Plan in an effort to more closely align the provider experience across Point32Health products. Please refer to that article for more information, including coding details.

In continuation of that work, we’d like to inform our provider network of two other prior authorization updates now in effect for Tufts Health Plan Commercial and Tufts Health Public Plans.

Coverage changes applicable to Tufts Health Plan Commercial and Public Plans
We’ve updated our Proton Beam Therapy Medical Necessity Guidelines (MNG) to allow coverage of proton beam therapy, with prior authorization, for the following indications:

  • Unresectable hepatocellular carcinoma
  • Intrahepatic cholangiocarcinoma
  • Intracranial arteriovenous malformation not amenable to surgical excision or other forms of treatment and/or adjacent to critical structures such as the optic nerve, brain stem or spinal cord

In addition, we noted in the February article that an integrated Point32Health coverage guideline was being developed for Intensity-Modulated Radiation Therapy. That MNG is now in effect, and as a result, prior authorization is no longer required for coverage of the associated codes 77385, 77386, G6015, and G6016 for Harvard Pilgrim Commercial members. This coverage without prior authorization aligns with the coverage already in place for Tufts Health Plan Commercial and Tufts Health Public Plans.

Audrey Kleinberg
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Senior Manager, Provider Communications

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