Please note the changes to the CCA Medical Necessity Guidelines outlined in the following chart. All are effective immediately except where otherwise noted. In addition to reviewing these policies, please refer to the CCA provider manuals for our notification, administrative authorization, and referral policies.
For the complete list of services that require prior authorization, please refer to “Section 4: Prior Authorization Requirements” in the CCA provider manuals. To access the provider manuals, please visit:
MA: commonwealthcarealliance.org/ma/providers/provider-manual-home/
RI: commonwealthcarealliance.org/ri/providers/provider-manual-home/
To access all Medical Necessity Guidelines, please visit:
MA: commonwealthcarealliance.org/ma/providers/medical-policies/medical-necessity-guidelines/
RI: commonwealthcarealliance.org/ri/providers/medical-policies/medical-necessity-guidelines/
CCA is retiring the following Medical Necessity Guidelines and Policies:
| Service | Products Impacted | Summary |
|---|---|---|
| Ramps, Vertical Platform (Wheelchair) Lift and Stair Lift: | SCO One Care | The Medical Necessity Guidelines for Ramps, Vertical Platform (Wheelchair) Lift, and Stair Lift Policy have been retired. Providers should refer to the recently updated Home Accessibility Adaptations Medical Necessity Guideline. |
The following services moved to the CCA Experimental & Investigational Services Medical Necessity Guideline:
| Service | Products Impacted | Summary |
|---|---|---|
| Chiropractor Services (CPT 22505) | SCO One Care MAPD HMO-DNSP (RI) | The Manipulation Procedures on the Spine policy (Vertebral Column) has moved to the Experimental & Investigational Services Medical Necessity Guideline. |
| Active Water Circulation (HCPCS E0218), (Effective 60 days from date of newsletter) | SCO One Care MAPD HMO-DNSP (RI) | The Active Water Circulation Policy (HCPCS E0218), Fluid Circulating Cold Pad with Pump, any type, is retired and has moved to the Experimental & Investigational Services Medical Necessity Guideline. |
The following service now require prior authorization:
| Service | Products Impacted | Summary |
|---|---|---|
| Radiofrequency Ablation (CPT 32988) | SCO One Care MAPD HMO-DNSP (RI) | Radiofrequency ablation, Under Other Procedures on the Lungs and Pleura |
| Skin and Soft Tissue Substitutes Effective (60 Days from notice) | SCO One Care MAPD HMO-DNSP (RI) | The following Skin and Soft Tissue Substitutes now require prior authorization: Q4103 Oasis burn matrix, per sq cm Q4108 Integra matrix, per sq cm Q4110 PriMatrix, per sq cm Q4111 GammaGraft, per sq cm Q4112 Cymetra, injectable, 1 cc Q4113 GRAFTJACKET XPRESS, injectable, 1 cc Q4114 Integra flowable wound matrix, injectable, 1 cc Q4121 TheraSkin, per sq cm Q4151 AmnioBand or Guardian, per sq cm Q4165 Keramatrix or Kerasorb, per sq cm Q4199 Cygnus matrix, per sq cm Q4251 Vim, per sq cm Q4252 Vendaje, per sq cm Q4253 Zenith Amniotic Membrane, per sq cm |
The following services no longer require prior authorization:
| CPT/HCPCS Code | Products Impacted | Summary |
|---|---|---|
| 93306 | SCO One Care MAPD HMO-DNSP (RI) | Echocardiography, transthoracic, real-time with image documentation (2d), includes m-mode recording, when performed, complete, with spectral doppler echocardiography, and with color flow doppler echocardiography |
| 71271 | SCO One Care MAPD RI DSNP | Computed tomography, thorax, low dose for lung cancer screening, without contrast material(s) |
| 76981 | SCO One Care MAPD HMO-DNSP (RI) | Ultrasound on liver density used to grade cirrhosis |
| S5160 S5161 | SCO One Care | Personal Emergency Response System and Home-Based Wandering Response System. |
| A9500-A9607 | SCO One Care MAPD HMO-DNSP (RI) | Radiopharmaceuticals |
| 70336, 70540, 70542, 70543, 70551, 70552, 70553, 70557, 70558, 70559, 71550, 71551, 71552, 72141, 72142, 72146, 72147, 72148, 72149, 72156, 72157, 72158, 72195, 72196, 72197, 73218, 73219, 73220, 73221, 73222, 73223, 73718, 73719, 73720, 73721, 73722, 73723, 74181, 74182, 74183, 77021, 77022, 77084 | SCO One Care MAPD HMO-DNSP (RI) | Magnetic resonance imaging |
| 93303, 93304, 93306, 93307, 93308, +93319, +93320, +93321, +93325, 93350, 93351, +93356 93312, 93313, 93314, 93315, 93316, 93317, 93318, +93319, +93320, +93321, +93325, 93355 | SCO One Care MAPD HMO-DNSP (RI) | Transthoracic and Transesophageal Echocardiograms |
| 77371, 77372, 77373, 77432, 77435 | SCO One Care MAPD HMO-DNSP (RI) | Radiation Oncology: Stereotactic body radiotherapy (SBRT) and Stereotactic radiosurgery (SRS) |
Changes to Prior Authorization Requirements
| Service Type | Products Impacted | Summary |
|---|---|---|
| Outpatient Physical Therapy and Occupational Therapy | SCO One Care MAPD HMO-DNSP (RI) | Effective February 8, 2024, after 20 visits per calendar year, prior authorization for Outpatient Physical Therapy and Occupational Therapy, including Intermittent skilled therapy in a nursing facility, requires prior authorization. Prior authorization for Outpatient Speech Therapy, including Intermittent skilled therapy in a nursing facility, requires prior authorization after 35 visits per calendar year. |
| Repairs and Modifications of Durable Medical Equipment (DME) | SCO and One Care only | Effective February 8, 2024, prior authorization for repair and modifications of durable medical equipment is required only when the cost of repair or modification exceeds $1,000. |
| Home Delivered Meals | SCO One Care | Effective March 14, 2024, prior authorization for Home Delivered Meals is required only when requesting 15 meals or more per week. |