As Point32Health continually works to integrate legacy Harvard Pilgrim Health Care and Tufts Health Plan policies and processes for an increasingly streamlined experience, we’re always assessing opportunities to make seeking and administering care less onerous for our members and providers — which includes reducing the number of services requiring prior authorization.
To that end, we’re making a number of updates, effective Jan. 1, 2024, to align coverage criteria and medical necessity guidelines (MNGs) with CMS for our Harvard Pilgrim StrideSM (HMO)/(HMO-POS) Medicare Advantage and Tufts Health One Care (the new name for Tufts Health Unify effective Jan. 1) plans.
Updates applicable to Stride criteria/MNGs
The following changes will take effect on Jan. 1, 2024 for Stride:
| Prior authorization will no longer be required for the following services: |
| Cholecystectomy surgery |
| Endoscopic sinus surgeries |
| Gender Affirming Care |
| Hysterectomy |
| Implantable Neurostimulators, including: Gastric Nerve Stimulation and Sacral Nerve Stimulation |
| Home Infusion Services |
| Cosmetic and reconstructive surgeries including: Hemangioma Treatment, Port Wine Stain Treatment, Surgical Scar Revision, and Excision of excess/ redundant skin |
| The following services will be moving from homegrown Harvard Pilgrim-specific criteria to guidance from the Centers for Medicare and Medicaid Services (CMS), including national coverage determinations (NCDs) and local coverage determinations (LCDs), as well as the CMS Medicare Manuals: |
| Gynecomastia |
| Implantable Neurostimulators including: Vagus Nerve Stimulation, Deep Brain and Spinal Cord Simulator |
| Medical Transportation |
| Cosmetic and reconstructive surgeries including: Panniculectomy |
Updates applicable to Tufts Health One Care criteria/MNGs
The following changes will apply as of Jan. 1 for Tufts Health One Care:
| Prior authorization will no longer be required for the following services: |
| Bronchial Thermoplasty |
| The following services will be moving from homegrown Tufts Health Plan criteria to CMS guidance, including LCDs, NCDs, and the CMS Medicare Manuals: |
| Proton Beam Therapy |
| Custom Fabricated Oral Appliances for Treatment of Obstructive Sleep Apnea |
| Lower Limb Protheses for general criteria |
| Hematopoietic Stem-Cell Transplantation (HSCT) for select diagnoses |
| Reconstructive and Cosmetic Surgery – Rhinoplasty, Gynecomastia, Breast Implant Removal, Breast Reduction, Panniculectomy |
| Non-Emergency Ambulance Transport – Air |
| Non-Emergency Ambulance Transport – Ground |
| Power Operated Vehicles (POVs) |
| Power Wheelchairs |
| Solid Organ Transplant – Heart |
| Solid Organ Transplant – Liver |
| Solid Organ Transplant – Pancreas – kidney transplant, pancreas transplant, pancreas islet |
| Solid Organ Transplant – Intestinal and Multi-visceral |
| Stereotactic Radiosurgery and Stereotactic Body Radiofrequency |
| The following will be moving from homegrown Tufts Health Plan criteria to MassHealth criteria: |
| Solid Organ Transplant – Lung |
| Solid Organ Transplant – Kidney |
| Video Capsule Endoscopy |
| The following services will be moving from InterQual criteria to CMS guidance, including LCDs, NCDs, and the CMS Medicare Manuals: |
| Bariatric Surgery |
| Blepharoplasty Upper/Lower Eyelid, Brow Ptosis Repair, Upper Eyelid Blepharoptosis Repair |
| Cholecystectomy, Laparoscopic |
| Hyperbaric Oxygen Treatment |
| Hysterectomy, Certain Elective |
| Implantable Neurostimulators |
| Manual Wheelchair |
| Osteogenesis Stimulators, Noninvasive |
| Outpatient PT, OT, ST |
| Oxygen and Respiratory Therapy Equipment |
| Percutaneous Posterior Tibial Nerve Stimulation |
| PAP Device for Tufts Health RITogether and One Care Products |
| Procedures for the Treatment of Benign Prostatic Hypertrophy |
| Procedure for the Treatment of Symptomatic Varicose Veins |
Updates applicable to Tufts Health Plan Medicare Preferred criteria/MNGs
The following changes will apply as of Jan. 1 for Tufts Health Medicare Preferred:
| The following services will begin to use CMS InterQual |
| Psychological and Neuropsychological Testing and Assessment for Tufts Health One Care and Tufts Health Medicare Preferred |
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