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 |
| Noncovered Investigational Services | Tufts Medicare Preferred, Tufts Health Plan Senior Care Options | 4/1/2025 | New MNG detailing services that will not be covered by Point32Health due to being considered experimental/investigational. For more information specific to this change, please see this article. |
| Genetic and Molecular Diagnostic Testing for Public Plans | Tufts Health RITogether | 4/1/2025 | In alignment with guidance from the Rhode Island Executive Office of Health and Human Services, prior authorization will be required for the oncology biomarker codes 0490U, 0491U, 0492U, and 0513U. |
| Gender Affirming Services | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health Together, Tufts Health RITogether, Tufts Health One Care | 2/1/2025 | Minor administrative update. |
| Intensity Modulated Radiation Therapy | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health Together, Tufts Health RITogether, Tufts Medicare Preferred, Tufts Health Plan Senior Care Options | 1/1/2025 | Effective retroactively to Jan. 1, 2025, prior authorization is no longer required for CPT code 77387 or HCPCS code G6017. |
| Genetic and Molecular Diagnostic Testing for Public Plans | Tufts Health One Care, Tufts Health Together | 11/21/2024 | Effective retroactively to Nov. 21, 2024, prior authorization is no longer required for CPT code 81420 (fetal chromosomal aneuploidy genomic sequence analysis panel), in support of guidance from MassHealth. |