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 | Harvard Pilgrim Commercial, Tufts Health Plan Commercial Tufts Health Direct, Tufts Health Together, Tufts Health RITogether, Tufts Health One Care | 6/1/2025 | The following services will no longer be covered:
The following services will now be eligible for coverage:
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| MassHealth Adjudicated Payment Amount per Discharge and Adjudicated Payment per Episode Carve Out Drugs | Tufts Health Together | 4/1/2025 | In accordance with MassHealth’s Managed Care Entity Bulletin 125, prior authorization review for all one-time infused cell and gene therapies identified on the MassHealth Acute Hospital Carve-Out Drug List found on this page (including Adjudicated Payment Amount per Discharge [APAD] and Adjudicated Payment per Episode of Care [APEC] drugs) will now be conducted through the MassHealth Drug Utilization Review (DUR) Program. These drugs must be submitted to the DUR Program for review and approval before administration, and MassHealth will pay the claims directly.To request prior authorization for one of these drugs via the MassHealth DUR program, you may submit the appropriate drug form from MassHealth’s Prior Authorization Forms for Pharmacy Services page by fax to (877) 208-7428. Please keep in mind that only authorization requests for the APAD and APEC drugs themselves will be reviewed by the MassHealth DUR program. You should continue to send all other requests, including the notification of the inpatient stay to administer the drug, to Point32Health. |
| Apos Therapy System | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Medicare Preferred | 4/1/2025 | New MNG detailing coverage of the Apos therapy system, an FDA-approved foot-worn biomechanical device used to reduce chronic knee and low back pain.
The Apos device has been shown to decrease use in opioids and can aid in delaying a member’s need for surgery. The device is indicated for members with knee osteoarthritis or chronic low back pain that has persisted despite conservative pain management methods such as physician therapy, pharmaceutical treatment, or lifestyle changes. Apos therapy system should be reported using CPT code 97799, and prior authorization is not required. |
| Clinical Trials | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health Together, Tufts Health RITogether, Tufts Health One Care | 4/1/2025
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Minor updates to criteria including clarification that Massachusetts requirements outlined on the policy only apply to clinical trials intended to treat cancer, as well as a coverage limitation for New Hampshire products that excludes the cost of an investigational new drug or device that is not approved for market for any indication by the FDA. |
| Reconstructive and Cosmetic Services | Tufts Health Together, Tufts Health One Care | 4/1/2025 | Rhinoplasty will now be reviewed using MassHealth criteria rather than InterQual criteria. |
| Continuous Glucose Monitoring and Diabetes Management Devices
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Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health RITogether, Tufts Health One Care | 4/1/2025 | Minor criteria updates to better align with current literature.
As a reminder, prior authorization is required for all codes identified on the policy, including CPT codes 0446T, 0447T, and 0448T. |
| Enteral Nutrition, Digestive Enzyme Cartridges and Special Medical Formulas for Tufts Health Together and Tufts Health One Care
Enteral Nutrition Products and Digestive Enzyme Cartridges for RITogether Oral Formulas and Enteral Nutrition |
Tufts Health Together, Tufts Health RITogether, Harvard Pilgrim Commercial, Tufts Health Plan Commercial,
Tufts Health One Care, Tufts Health Direct |
4/1/2025 | Minor updates to criteria for Relizorb digestive enzyme cartridge to more closely reflect FDA labeling. |
| MassHealth guidelines for treating erectile dysfunction | Tufts Health Together, Tufts Health One Care | 4/1/2025 | HCPCS code L7900 will be covered without prior authorization for Tufts Health Together and Tufts Health One Care. |
| Evolent diagnostic cardiology guidelines | Harvard Pilgrim Commercial | 4/1/2024 | Prior authorization is no longer required for CPT code 93325 (Doppler color flow imaging technique). Prior authorization was previously managed through Evolent’s cardiac diagnostic program for Harvard Pilgrim Commercial plans, but will no longer be required in alignment with Point32Health’s other lines of business. |
| Clinical Review of Dental Services in the Medical Benefit | Harvard Pilgrim Commercial | 3/1/2025 | When requesting prior authorization for surgical dental procedures, providers may now submit CPT code 41899 (unlisted procedure, dentoalveolar structures), when appropriate. |
| Tufts Medicare Preferred (HMO and PPO) Prior Authorization, Notification, and No Prior Authorization
Tufts Health Senior Care Options Prior Authorization, Notification, and No Prior Authorization |
Tufts Medicare Preferred, Tufts Health Plan Senior Care Options | 1/1/25 | Prior authorization is no longer required for CPT codes 93970 and 93971 related to the treatment of varicose veins. |