CareLink℠ Procedures, Services and Items Requiring Prior Authorization
Updated: March 2020
Prior authorization may be required for certain procedures/items/services for CareLink members. Due to the evolving information regarding existing procedures and nature of new and emerging technology, providers should contact Cigna at 800.CIGNA24 to verify specific prior authorization requirements. If required, a prior authorization request may be submitted at that time (additional clinical information or clarification may be needed). Cigna conducts utilization review for CareLink members and will apply medical necessity guideline criteria for procedures/services/items requiring prior authorization, including but not limited to the list below.
Note: Inpatient admissions require inpatient notification, even if prior authorization has been obtained. Members are responsible for inpatient notification only when services are unauthorized or provided by out-of-network providers. For questions about medical management policies, contact Cigna at 800.CIGNA24 or refer to Cigna's website.
- Behavioral health services (e.g., ABA services, rTMS treatment)*
- Continuous glucose monitoring systems
- Cosmetic (plastic) and/or potentially cosmetic procedures (e.g., abdominoplasty or scar revisions)
- Durable medical equipment, including orthotics and prosthetics
- Experimental/investigational procedures
- Genetic testing
- High-tech imaging
- Home care services (e.g., private duty/independent nursing)
- Hospice services
- Certain medical drugs
- Nonemergency ambulance transportation
- Post-acute services (e.g., SNF, hospice, TCU and inpatient rehabilitation)
- Proton beam therapy
- Sleep studies
- Speech therapy
- Stereotactic radiosurgery
- Surgical procedures
- Transplants (except corneal)
- Varicose vein treatments
*Contact Tufts Health Plan for benefit determinations for behavioral health services at 866.352.9114.