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:
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:
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| 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:
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| 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:
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| 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:
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| 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
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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:
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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. |
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