| Updates to Medical Necessity Guidelines (MNG) | |||
| MNG Title | Products Affected | Effective Date | Summary |
| Laser Vision Correction Surgery | Tufts Health One Care | Jan. 1, 2024 | MNG updated to remove reference to Tufts Health One Care as an applicable product, consistent with benefits for this product. As a result, codes 65772, 65775, S0800, S0810, and S0812 are not covered for Tufts Health One Care. |
| Tumor Treating Fields (Harvard Pilgrim) | Harvard Pilgrim Health Care commercial, Tufts Health Plan commercial, Tufts Health Public Plans | Jan. 1, 2024 | Prior authorization is no longer required, and the policy will be maintained only as a coverage guideline. |
| Bronchial Thermoplasty | Harvard Pilgrim Health Care commercial, Tufts Health Plan commercial, Tufts Health Public Plans | Jan. 1, 2024 | Prior authorization is no longer required, and the associated MNG has been retired. |
| Implantable Pulmonary Artery Pressure Monitor (CardioMEMS) (Harvard Pilgrim)
Implantable Pulmonary Artery Pressure Monitor (CardioMEMS) (Tufts Health Plan) |
Harvard Pilgrim Health Care commercial, Tufts Health Plan commercial, Tufts Health Direct, Tufts Health Together, Tufts Health RITogether | March 1, 2024 | New MNG outlining coverage of CardioMEMS HF (Heart Failure), an implantable pulmonary artery pressure monitor system. Codes 33289, 93264, and C2624 are now covered, and prior authorization is required. |
| Clinical Review of Dental Services in Medical Benefit | Harvard Pilgrim Health Care commercial | Jan. 1, 2024 | Minor criteria updates to provide greater clarity regarding the definition of emergency dental care, as well as coverage of the use of general anesthesia and monitored anesthesia care. |
| Power Wheelchairs for Tufts Health Together, Tufts Health RITogether, and Tufts Health One Care | Tufts Health Together, Tufts Health RITogether, Tufts Health One Care | Jan. 1, 2024 | MNG updated to align with national coverage determinations and local coverage determinations, as well as guidelines from MassHealth and the Executive Office of Health and Human Services.
Among other updates:
|
| Power Operated Vehicles (POVs) for Tufts Health Together, Tufts Health RITogether, and Tufts Health One Care | Tufts Health Together, Tufts Health RITogether, Tufts Health One Care | Jan. 1, 2024 | Criteria replaced by local coverage determinations and guidelines from the Executive Office of Health and Human Services.
Limitation removed from home modification limitation, and HCPCS codes K0812 and E1230 have been removed from the policy and will no longer require prior authorization.
|
| Hematopoietic Stem Cell Transplantation | Tufts Health Plan commercial, Tufts Health Public Plans | Jan. 1, 2024 | Removing a number of codes from the MNG. Some of the codes previously required prior authorization, and some did not, but prior authorization is no longer required for any of the following: 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38242, S2140, S2142, S2150 |
| Dental Implants | Tufts Health Plan commercial | Jan. 1, 2024 | Minor language clarification related to authorization of coverage.
|
| Donor Breast Milk for Maine Products | Harvard Pilgrim commercial (Maine only) | Jan. 1, 2024 | New clinical coverage guideline created in support of the recent Maine state mandate. For Harvard Pilgrim commercial members living in Maine or who have a Maine based plan, pasteurized, banked donor breast milk (HCPCS code T2101) may be considered reasonable and medically necessary and covered without prior authorization when the criteria on the policy have been met. |
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