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 |
| Gender Affirming Services | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Public Plans | 3/1/2025 | Prior authorization is no longer required for the following CPT codes associated with adjacent tissue transfer or rearrangement. These codes are open to pay for all medically necessary indications:
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| 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 diagnostic ultrasound procedure codes 76981, 76982, and 76983 will be covered when they are billed with one of the ICD-10 diagnosis codes identified on the MNG, as appropriate. If billed with any other diagnosis code, they will continue to deny as experimental/investigational. |
| Intensity-Modulated Radiation Therapy (IMRT) | All products | 1/1/2025 | Prior authorization is no longer required for CPT codes 77301 and 77338. |