Beginning on July 1, 2020, Harvard Pilgrim will be adopting InterQual criteria for commercial medical review of oral devices for obstructive sleep apnea. As of this date, Harvard Pilgrim will require prior authorization for coverage of HCPCS code E0486 (Oral device/appliance used to reduce upper airway collapsibility, adjustable or nonadjustable, custom fabricated, includes fitting and adjustment).
As a reminder, HCPCS code E0485 (Oral device/appliance used to reduce upper airway collapsibility, adjustable or nonadjustable, prefabricated, includes fitting and adjustment) is considered not medically necessary and is not covered.
With the adoption of InterQual criteria, when submitting your authorization request through HPHConnect, an electronic authorization questionnaire will guide you through the criteria. For guidance on using HPHConnect to request an authorization and accessing the InterQual criteria, refer to this training presentation. To request additional training, contact us at Provider_Experience@harvardpilgrim.org.
For more information, please refer to the updated Oral Devices for Obstructive Sleep Apnea Medical Policy. You may view and print the applicable SmartSheet questionnaire via HPHConnect (go to www.harvardpilgrim.org/providerportal, select Resources and then the Upcoming InterQual link).