Spinal Conditions Management Program
Tufts Health Plan requires providers to obtain prior authorization through National Imaging Associates (NIA) for interventional pain management, lumbar and cervical spine surgeries for members of the following Commercial and Tufts Health Public Plans products:
- Commercial products, include HMO, POS, PPO, and Uniformed Services Family Health Plan (USFHP)
- Tufts Health Direct
- Tufts Health RITogether
- Tufts Health Together – MassHealth MCO Plan and Accountable Care Partnership Plans
Note: The NIA Spinal Conditions Management Program does not apply to members of Senior Products (including Tufts Medicare Preferred HMO and Senior Care Options [SCO]), Commercial PPO plans with the Cigna network, CareLinkSM, or Tufts Health One Care.
While you may not be the provider responsible for obtaining prior authorization, as a condition of payment, you must confirm that prior authorization has been obtained. To request and verify authorizations or access medical necessity guidelines, providers may log in to RadMD or call 866.642.9703 for Tufts Health Plan products or 800.207.4209 for Tufts Health Public Plans products.
NIA does not manage the prior authorization for emergency spinal condition or musculoskeletal procedures through the emergency department or for spinal condition or musculoskeletal procedures outside those listed below.
Facilities or hospitals performing musculoskeletal surgeries requiring inpatient admission must adhere to the Tufts Health Plan inpatient notification requirements. Inpatient notification must be obtained through Tufts Health Plan’s Precertification Department and only initiated after the surgery has met NIA’s medical necessity criteria. For more information, refer to the Inpatient Facilities Payment Policy for Commercial or Tufts Health Public Plans.
Nonemergent Outpatient Interventional Spine Pain Management
The ordering provider must request prior authorization for the following nonemergent outpatient interventional spine pain management services:
- Spinal epidural injections
- Paravertebral facet joint injections or blocks
- Paravertebral facet joint denervation (radiofrequency [RF] neurolysis)
Note: Interventional pain management (IPM) spine services rendered in the emergency department (ED), observation, or hospital inpatient setting are not subject to prior authorization. Each IPM procedure requires an individual prior authorization. Due to the repeat nature of IPM procedures, multiple authorizations may exist within the same validity period. NIA does not pre-approve a series of epidural injections.
Nonemergent Inpatient and Outpatient Spine Surgeries
The ordering provider must request prior authorization for the following nonemergent inpatient and outpatient spine surgeries:
- Lumbar microdiscectomy
- Lumbar decompression (laminotomy, laminectomy, facetectomy & foraminotomy)
- Lumbar spine fusion (arthrodesis) with or without decompression – single & multiple levels
- Cervical anterior decompression with fusion – single and multiple levels
- Cervical posterior decompression with fusion – single and multiple levels
- Cervical posterior decompression (without fusion)
- Cervical artificial disc replacement
- Cervical anterior decompression (without fusion)
Using evidence-based criteria and guidelines, NIA will review coverage requests and provide authorizations for these services. For a list of procedure codes subject to prior authorization by NIA, refer to the Spinal Conditions Management Program Code Matrix or visit the NIA portal, RadMD, to access medical necessity guidelines.