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)
To view these guidelines, visit the Medical Necessity Guidelines page on our Point32Health provider website |
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| MNG Title | Products Affected | Effective Date | Summary |
| Procedures for the Treatment of Symptomatic Varicose Veins | Tufts Health Together, Tufts Health RITogether, Tufts Health Direct | 7/1/2024 | Prior authorization will be required for a number of codes pertaining to the treatment of varicose veins:
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| Gender Affirming Services
Hyperbaric Oxygen Treatment (HBO) Reconstructive and Cosmetic Surgery Removal of Benign Skin Lesions (Harvard Pilgrim Commercial only) Surgical Treatments for Lymphedema Blepharoplasty, Upper/Lower Eyelid, and Brow and/or Eyelid Ptosis Repair Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI) Laser Vision Correction Surgery |
Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Together, Tufts Health RITogether, Tufts Health Direct, Tufts Health One Care | 5/1/2024 | Annual review of a number of MNGs related to plastics and ophthalmology (no changes). |
| Noncovered Investigational Services | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Together, Tufts Health RITogether, Tufts Health Direct, Tufts Health One Care | 5/1/2024 | The following have been removed from the MNG and are now covered with prior authorization through our arrangement with Carelon:
The following have been added to the MNG and will not be covered:
CPT codes 76391 and 0649T have been removed from the MNG and are now covered with prior authorization, and HCPCS code S9002 has been added to the MNG and will not be covered. |
| Cochlear Implants | Harvard Pilgrim Commercial, Tufts Health Direct | 2/1/2023 | Effective retroactively to Feb. 1, 2023, we’ve updated the MNG to include coverage for the ICD-10 diagnosis code H90.3 (sensorineural hearing loss, bilateral), which will be covered only when billed alongside one of the following CPT codes: 69930, L8614, or L8619 |
| Genetic Testing: Whole Exome Sequencing and Whole Genome Sequencing | Tufts Health Plan Commercial | 5/1/2024 | New MNG to document our existing coverage and prior authorization requirements for whole genome sequencing and whole exome sequencing for Tufts Health Plan Commercial products.
No change in current coverage, criteria, or prior authorization. |
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