The chart below identifies updates to our Medical Necessity Guidelines. For additional details, refer to the Medical Necessity Guidelines page on our Point32Health provider website, where you can find coverage and prior authorization criteria for our Harvard Pilgrim and Tufts Health Plan lines of business.
| Updates to Medical Necessity Guidelines (MNG) | |||
| MNG Title | Products Affected | Effective Date | Summary |
| Total Joint Replacement – Ankle | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct | 3/1/2025 | New MNG for a newly covered service, and prior authorization will be required.
Will use InterQual criteria for review. Providers who meet the InterQual criteria can receive on-the-spot approvals by using HPHConnect or our Tufts Health Plan secure provider portal. |
| Ankle Arthroscopy | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct | 3/1/2025 | New MNG for a newly covered service, and prior authorization will be required.
Will use InterQual criteria for review. Providers who meet the InterQual criteria can receive on-the-spot approvals by using HPHConnect or our Tufts Health Plan secure provider portal. |
| Hematopoietic Stem Cell Transplantation | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health Together, Tufts Health RITogether, Tufts Health One Care | 3/1/2025 | Updates to criteria for clarification.
In addition, prior authorization will be newly required for Tufts Health RITogether. |
| Intensity-Modulated Radiation Therapy | Tufts Health One Care | 3/1/2025 | Tufts Health One Care will be added to the existing MNG as an applicable product, and prior authorization will be required for the following CPT codes for intensity-modulated radiation therapy:
77301, 77338, 77385, 77386, 77387, G6015, G6016, and G6017. |
| Bioengineered Skin Substitutes | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct | 3/1/2025 | New MNG outlining coverage criteria for bioengineered skin substitutes. The following HCPCS codes will be covered only when they are billed with one of the ICD-10 diagnosis codes specified on the MNG: C9363, Q4100, Q4101, Q4102, Q4104, Q4105, Q4106, Q4107, Q4108, Q4110, Q4116, Q4121, Q4122, Q4124, Q4128, Q4132, Q4133, Q4151, Q4168, Q4182, Q4186, and Q4187.
In addition, TheraSkin (HCPCS code Q4121) will be covered when billed with an appropriate ICD-10 code. |
| Removal of Benign Skin Lesions | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct | 3/1/2025 | Codes 17000, 17003, 17004, 17100, 17111 will be covered only when submitted for certain diagnoses, following guidance in CMS article A54602. See MNG for details, including a list of covered ICD-10 codes. |
| Noncovered Investigational Services | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health Together, Tufts Health RITogether, Tufts Health One Care | 3/1/2025 | The following services/codes will be added to the Noncovered Investigational Services MNG as experimental/investigational and will deny if billed:
|
| Hypoglossal Nerve Stimulation | Tufts Medicare Preferred, Tufts Health Plan Senior Care Options | 3/1/2025 | New MNG outlining our newly developed internal criteria, and prior authorization will be required. |
| Tufts Medicare Preferred (HMO and PPO) Prior Authorization, Notification, and No Prior Authorization Medical Necessity Guidelines | Tufts Medicare Preferred | 3/1/2025 | Prior authorization will be required for the Intracept procedure (basivertebral nerve ablation, CPT codes 64628 and 64629), and CMS’ local coverage determination L39642 will be used for criteria.
In addition, new prior authorization requirements added for the following:
|
| Tufts Health Senior Care Options Prior Authorization, Notification, and No Prior Authorization Medical Necessity Guidelines | Tufts Health Plan Senior Care Options | 3/1/2025 | Prior authorization will be required for the Intracept procedure (basivertebral nerve ablation, CPT codes 64628 and 64629), and CMS’ local coverage determination L39642 will be used for criteria.
In addition, new prior authorization requirements added for the following:
|
| Tufts Health One Care Prior Authorization, Notification, and No Prior Authorization Medical Necessity Guidelines | Tufts Health One Care | 3/1/2025 | Prior authorization will be required for the Intracept procedure (basivertebral nerve ablation, CPT codes 64628 and 64629), and CMS’ local coverage determination L39642 will be used for criteria. |
| Lyme Disease: Antibiotic Coverage | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health Together, Tufts Health RITogether, Tufts Health One Care | 1/1/2025 | Criteria updated to include language for short-term antibiotic treatment. |
| Magnetic Resonance Elastography (MRE) for Chronic Liver Disease | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health Together, Tufts Health RITogether, Tufts Health One Care | 1/1/2025 | New interim MNG for prior authorization criteria.
We previously communicated that our vendor partner Evolent would be performing prior authorization review for this service. However, Evolent will not be reviewing this service until July 1, 2025. From Jan. 1, 2025 until July 1, 2025, Point32Health will review prior authorization requests for MRE for chronic liver disease in-house. |
| Dental Procedures Requiring Hospitalization | Tufts Health Plan Commercial | 1/1/2025 | Updates to criteria. |
| Oral Formula and Enteral Nutrition | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct | 1/1/2025 | Minor criteria updates, including the addition of criteria requesting that providers submit a growth chart to document growth failure and updates to Relizorb criteria due to FDA label expansion. |
| Oral Formulas for Rhode Island Commercial | Harvard Pilgrim Commercial | 1/1/2025 | Criteria updated for additional clarity. As a reminder, prior authorization is required. |
| Basivertebral Nerve Ablation | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health RITogether, Tufts Health One Care | 1/1/2025 | New MNG outlining coverage criteria for the Intracept procedure (basivertebral nerve ablation, CPT codes 64628 and 64629) which is now covered with prior authorization. |
| Solid Organ Transplants (Heart, Heart/Lung, Intestinal, Kidney, Liver, Lung, Pancreas, Pancreas/Kidney) | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health Together, Tufts Health RITogether, Tufts Health One Care | 1/1/2025 | New streamlined MNG to outline all solid organ transplant criteria in one location. Criteria updated in accordance with transplant guidelines. |
| Subcutaneous Implantable Cardioverter Defibrillator | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health Together, Tufts Health RITogether, Tufts Health One Care | 1/1/2025 | Minor updates to criteria based on literature review. Prior authorization is not required. |
| Transcatheter Mitral Valve Repair | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health Together, Tufts Health RITogether, Tufts Health One Care | 1/1/2025 | Minor updates to criteria and limitations based on literature review and manufacturer label. Prior authorization is not required.
Added definition of “prohibitive risk” and “moderate to severe mitral regurgitation.” |
| Genetic Testing: Whole Exome Sequencing and Whole Genome Sequencing | Tufts Health Plan Commercial | 1/1/2025 | Minor updates to criteria. |
| Genetic and Molecular Diagnostic Testing | Tufts Health Plan Commercial | 1/1/2025 | Minor updates to criteria. |
| Genetic Testing: Cell Free DNA Screening for Fetal Trisomy | Tufts Health Plan Commercial | 1/1/2025 | Minor updates to criteria. |
| Genetic Testing: BRCA1 and BRCA2 – Hereditary Breast, Ovarian, and Pancreatic Cancers | Tufts Health Plan Commercial | 1/1/2025 | Criteria updates to align with most up-to-date National Comprehensive Cancer Network guidelines and literature. |
| Home Health Care Services for Tufts Together, Tufts Health RITogether, and Tufts Health One Care | Tufts Health Together, Tufts Health RITogether, Tufts Health One Care | 1/1/2025 | MNG reformatted and criteria updated for additional clarity and to reflect MassHealth requirements. |
| In-Home Therapy Services for Tufts Health Together | Tufts Health Together | 1/1/2025 | New in-house Point32Health MNG to reflect MassHealth criteria. |
| In-Home Behavioral Services for Tufts Health Together | Tufts Health Together | 1/1/2025 | New in-house Point32Health MNG to reflect MassHealth criteria. |
| Intensive Care Coordination for Tufts Health Together | Tufts Health Together | 1/1/2025 | New in-house Point32Health MNG to reflect MassHealth criteria. |
| Mobile Crisis Intervention for Tufts Health Together | Tufts Health Together | 1/1/2025 | New in-house Point32Health MNG to reflect MassHealth criteria. |
| Community Support Programs | Tufts Health Together, Tufts Health One Care, Tufts Health Plan Senior Care Options | 1/1/2025 | Criteria updated to align with MassHealth guidance. |
| Acute Hospital Care at Home | All products | 1/1/2025 | New MNG outlining criteria and notification requirements. |