The Spinal Conditions Management Program applies to Tufts Health Plan Commercial products* and Tufts Health Public Plans** products.
*Commercial products include HMO, POS, PPO, and Uniformed Services Family Health Plan (USFHP).
Note: Effective October 1, 2018, USFHP is included in the Spinal Condition Management program.
**Tufts Health Public Plans products include Tufts Health Direct, Tufts Health RITogether, and Tufts Health Together – MassHealth MCO Plan and Accountable Care Partnership Plans.
Providers must request prior authorization for interventional pain management, lumbar and cervical spine surgeries for Commercial and Tufts Health Public Plans members. Using evidence-based criteria and guidelines, NIA will review coverage requests and provide authorizations for these services. To obtain 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.
Prior authorization is required 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 spine services rendered in the emergency department (ED), observation, or hospital inpatient setting are not subject to prior authorization. Each IPM procedure requires a 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.
Prior authorization will be required 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)
For a list of procedure codes subject to prior authorization by NIA, refer to the Spinal Conditions Management Program Code Matrix.
Note: This program is also documented in the Tufts Health Public Plans Covered Services Grids.
This program does not apply to members of Tufts Medicare Complement, Commercial PPO plans with the PHCS network, CareLinkSM
, Tufts Health Unify, Tufts Medicare Preferred HMO, Tufts Medicare Preferred Supplement, or Tufts Health Plan Senior Care Options (SCO).