Point32Health Medical Necessity Guideline updates

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
New prior authorizations for Point32Health Senior Products	Tufts Medicare Preferred, Tufts Health Plan Senior Care Options	1/1/2025	Point32Health will be newly requiring prior authorization for a number of services/codes for Tufts Medicare Preferred and Tufts Health Plan Senior Care Options as of Jan. 1, 2025. Please refer to this article for further information about MNGs being updated to require additional prior authorizations for Senior Products.
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	Prior authorization will be required for the following codes: 77338 77301 77385 77386 77387 G6015 G6016 G6017 Please note that members receiving intensity-modulated radiation therapy (IMRT) prior to Jan. 1, 2025 will not be impacted by this new prior authorization requirement. All members starting IMRT on or after Jan. 1, 2025 will require prior authorization. In alignment with the Out of Network at the In Network Level of Benefit and Continuity of Care Medical Necessity Guidelines, all members who are in an active course of IMRT prior to Jan. 1, 2025 will have 90 days’ continuity of care starting Jan. 1, 2025 and do not need to obtain a prior authorization for that course of treatment.
Noncovered Investigational Services	Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Public Plans	1/1/2025	The following services will be added to the Noncovered Investigational Services MNG and will no longer be covered: Dry Needling (CPT codes 20560 and 20561) Posterior Vertebral Body Tethering RelieVRx
Evolent criteria	Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health Together, Tufts Health RITogether	1/1/2025	Minor updates to Evolent’s criteria. Evolent (formerly National Imaging Associates, Inc./NIA) oversees prior authorization programs for select Point32Health products for certain services, including cardiac diagnostic tests and interventional procedures; high-tech diagnostic imaging; select joint procedures; spine surgery and cervical spine procedures; and outpatient interventional spine pain management services.
Remote Patient Monitoring	Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health RITogether, Tufts Medicare Preferred	11/1/2024	MNG updated to only apply to the products listed to the left. Minor criteria updates made for additional clarity: Requirement that a physician or qualified healthcare practitioner has documented the member’s condition is at high risk for instability or deterioration Requirement that member has risk factors which places them at risk for ED or hospitalization For new members to the physician’s practice or in the event that a member has not seen the practitioner within one year, the practitioner must first conduct a face-to-face or telehealth visit with the member to initiate remote patient monitoring
Remote Patient Monitoring	Tufts Health Together, Tufts Health Plan Senior Care Options, Tufts Health One Care	11/1/2024	Separate Remote Patient Monitoring MNG developed specifically for the products identified at left. This version incorporates guidance from MassHealth, including coverage without prior authorization for the following additional diagnoses: Asthma Chronic obstructive pulmonary disease Congestive heart failure Type I or II diabetes mellitus Hypertension Perinatal from pregnancy through 12 months post delivery
Hospice and Palliative Care Services	Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct	11/1/2024	Because InterQual’s content no longer includes criteria for hospice care, we’ve updated the MNG to apply our own Point32Health hospice criteria, which notes that the following are required for coverage: The member or “appointment designee” elects or continues to elect hospice care There is a caregiver in the member’s home who is willing and capable of assisting the member The hospice services are provided by a certified/accredited hospice agency with care available 24 hours per day, seven days per week
Assisted Reproductive Technology Services – Maine Products Assisted Reproductive Technology Services – Massachusetts Products Assisted Reproductive Technology Services – Rhode Island Products Assisted Reproductive Technology Services – New Hampshire Products	Harvard Pilgrim Commercial, Tufts Health Plan Commercial	11/1/2024	In alignment with guidance from state regulatory agencies, Point32Health has updated our cryopreservation and storage benefit for Commercial, fully insured members to include coverage for ovarian tissue and testicular tissue, in addition to the existing coverage for sperm, eggs, and embryos. CPT codes 89335, 89344, 89354, and 89398 will now be covered with prior authorization when the criteria on the applicable MNG is met. Refer to this article, also in this issue of Insights and Updates for Providers, for more details – including information about the Cryopreservation Attestation Form for Maine members.
Vitamin D Screening and Testing Non-Emergency Medical Transportation (Air/Ground) Continuous Glucose Monitoring and Diabetes Management Devices	Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Public Plans	11/1/2024	Upon annual review of these MNGs, Point32Health has incorporated minor criteria updates to provide additional clarity.
Vitamin B12 Screening and Testing Behavioral health-related MNGs: Behavioral Health Inpatient and 24-Hour Level of Care Determinations Behavioral Health Level of Care for Non-24 Hour/Intermediate/Diversionary Services Psychological and Neuropsychological Testing and Assessment Tufts Health Plan One Care and Tufts Health Plan Medicare Preferred Transcranial Magnetic Stimulation (rTMS) Transcranial Magnetic Stimulation (TMS) for Tufts Health Unify, Tufts Medicare Preferred and Tufts Health Plan Senior Care Options Applied Behavioral Analysis (ABA) Therapy and Habilitative Services for Autism Spectrum Disorders ABA (Applied Behavioral Analysis) Therapy for Autism Spectrum Disorders: Rhode Island Products Behavioral Health Applied Behavioral Analysis (ABA) including Early Intervention: RITogether Behavioral Health Enhanced Outpatient Services (EOS) Home and Community Based Services (HBTS) Behavioral Health: Acupuncture Detoxification Level of Care Behavioral Health: Opioid Treatment Services (Methadone Maintenance) Level of Care Community Support Programs including Specialized Community Support Program Early Intensive Behavioral Intervention (EIBI) Behavioral Health: Evidence-Based Practices (EBP) Family Stabilization Treatment (FST) Criteria for Behavioral Health Services In-Home Behavioral Services (IHBS): Massachusetts Products In-Home Therapy Services (IHTS): Massachusetts Products Intensive Hospital Diversion (IHD), Mobile Crisis Intervention (MCI) for Youths: Massachusetts Products Outpatient Psychotherapy Personal Assistance Services & Supports (PASS) Program of Assertive Community Treatment (PACT) Services Peer Recovery Coach Recovery Support Navigator Respite for Children – RITogether Respite Care for Tufts Health One Care Targeted Case Management Services: Intensive Care Coordination (ICC): Massachusetts Products	All products	11/1/2024	Point32Health has conducted our annual review of the Vitamin B12 Screening and Testing MNG, as well as a number of MNGs related to behavioral health services, with no changes.

Point32Health Medical Necessity Guideline updates

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