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 |
| Outpatient Pulmonary Rehabilitation | Harvard Pilgrim Commercial | 1/1/2025 | Prior authorization will no longer be required for the outpatient pulmonary rehabilitation CPT codes 94625 and 94626, and the MNG will be archived. |
| Applied Behavioral Analysis Therapy for Autism Spectrum Disorder for Tufts Health Together | Tufts Health Together | 1/1/2025 | MNG updated to align with MassHealth’s changes to contracting requirements, Medical Necessity Guidelines, and performance specifications, as referenced in this article from the November 2024 issue of Insights and Updates for Providers. |
| Lower Limb Prostheses
Upper Limb Prostheses |
Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health Together, Tufts Health RITogether, Tufts Health One Care | 1/1/2025 | Eliminating step through requirement of mechanical knee before members can receive a microprocessor knee at the K2 level. In addition, in support of recent state guidance, coverage will be offered for recreational upper and lower limb prosthetics for New Hampshire members under age 19. |
| Neuropsychological and Psychological Testing and Assessment | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health Together, Tufts Health RITogether | 12/1/2024 | Utilizing Point32Health criteria rather than InterQual criteria. Retiring the Neuropsychological Testing and Assessment MNG and Psychological Testing and Assessment MNG, as that information is reflected in this combined policy. |
| Long-Term Services & Supports (LTSS) for Tufts Health One Care | Tufts Health One Care | 12/1/2024 | Day habilitation criteria revised to align with MassHealth requirements. |
| Proton Beam Therapy | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health Together, Tufts Health RITogether, Tufts Health One Care | 12/1/2024 | Added clarifying language related to types of skull-based tumors and criteria for coverage of the treatment of pediatric tumors. |
| Implantable Neurostimulators
Mohs Micrographic Surgery (MMS) UVB Home Units for Skin Disease Clinical Trials: Routine Costs Lyme Disease: Antibiotic Coverage Urine Drug Testing |
Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health Together, Tufts Health RITogether, Tufts Health One Care | 12/1/2024 | Annual review, no changes. |
| Manual Wheelchairs for Tufts Health Together, Tufts Health RITogether and Tufts Health One Care
Outpatient Physical Therapy, Occupational Therapy, and Speech Therapy (Public Plans) Power Operated Vehicles (POVs) for Tufts Health Together, Tufts Health RITogether, and Tufts Health One Care Power Wheelchairs for Tufts Health Together, Tufts Health RITogether, and Tufts Health One Care (Public Plans) High-Cost Durable Medical Equipment (DME), Adaptive Strollers and Speech Generating Devices Hospice Services for Tufts Health Together, Tufts Health RITogether, and Tufts Health One Care |
Tufts Health Together, Tufts Health RITogether, Tufts Health One Care | 12/1/2024 | Annual review, no changes. |
| Outpatient Habilitative Services for Physical Therapy, Occupational Therapy and Speech Therapy
Outpatient Rehabilitative Services: Occupational Therapy (Commercial; Public Plans) Outpatient Rehabilitative Services: Physical Therapy Commercial; Public Plans Outpatient Rehabilitative Services: Speech Therapy Commercial; Public Plans Autism Services: Physical, Occupational, and Speech Therapy for Members with Autism Spectrum Disorders |
Tufts Health Plan Commercial, Tufts Health Direct | 12/1/2024 | Annual review, no changes. |
| Power Operated Vehicles (POVs)
Power Wheelchair |
Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct | 12/1/2024 | Annual review, no changes. |
| Adult Medical Day Care for Tufts Health RITogether
Extended Home Care Services, Tufts Health RITogether |
Tufts Health RITogether | 12/1/2024 | Annual review, no changes. |
| Home Accessibility Adaptations | Tufts Health Together, Tufts Health One Care, Tufts Health Plan Senior Care Options | 12/1/2024 | Annual review, no changes. |
| Home Health Care Services | Harvard Pilgrim Commercial | 12/1/2024 | Annual review, no changes. |
| Out-of-Network Outpatient Dialysis at the In-Network Level of Benefits
Private Duty Nursing in the Home (Commercial) |
Tufts Health Plan Commercial | 12/1/2024 | Annual review, no changes. |
| Family Support and Training | Tufts Health Together | 9/15/2024 | Revised MNG in alignment with recent revisions associated with Children’s Behavioral Health Initiative (CBHI) services from MassHealth and the Executive Office of Health and Human Services (EOHHS), as referenced in this article from the November 2024 issue. |
| Therapeutic Monitoring Services | Tufts Health Together | 9/15/2024 | Revised MNG in alignment with recent revisions associated with CBHI services from MassHealth and the EOHHS, as referenced in this article from the November 2024 issue. |