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 |
| Inpatient Acute and Post Acute Levels of Care (Medical/Surgical) | Tufts Health Together, Tufts Health RITogether, Tufts Health One Care | 8/1/2025 | Language updated to reflect that we will no longer authorize observation stays longer than 48 hours for members of our Tufts Health Together, Tufts Health RITogether, and Tufts Health One Care plans.
Refer to this article for more information. |
| Magnetic Resonance Guided Focused Ultrasound (MRgFUS) | Harvard Pilgrim Commercial, Tufts Health Direct, Tufts Health Together, Tufts Health RITogether | 6/1/2025 | New MNG for MRgFUS, which will allow coverage of CPT code 61715 when submitted with a diagnosis code for essential tremors.
Prior authorization is not required. |
| Custom Fabricated Oral Appliances
Positive Airway Pressure (PAP) Devices Positive Airway Pressure (PAP) Devices for Tufts Health RITogether and Tufts Health One Care Manual Wheelchairs Manual Wheelchairs for Tufts Health Together, Tufts Health RITogether, and Tufts Health One Care |
Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health Together, Tufts Health RITogether, Tufts Health One Care | 6/1/2025 | Criteria update related to damage coverage. Product applicability varies by policy. |
| Hyperbaric Oxygen Treatment (HBO) | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health Together, Tufts Health RITogether, Tufts Health One Care | 6/1/2025 | Criteria updated to more clearly identify coverage limitations. |
| EviCore criteria | Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health Together, Tufts Medicare Preferred | 6/1/2025 | Prior authorization is no longer required for the following codes for home sleep tests:
Please note that prior authorization is still required for facility-based sleep tests. |
| Bioengineered Skin and Soft Tissue Substitutes
|
Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct | 6/1/2025 | Codes Q4132, Q4133, Q4151, and Q4168 related to bioengineered skin and soft tissue substitutes are now covered when prior authorization criteria are met. |