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 |
| Dental Procedures Requiring Hospital/Facility-Based Care for Tufts Health Direct, Tufts Health Together, RITogether
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Tufts Health Direct, Tufts Health Together, Tufts Health RITogether | 7/1/2025 | New MNG specific to dental procedures performed in an acute care inpatient facility or ambulatory surgical center, as well as the administration of general anesthesia associated with dental procedures in a hospital setting.
While the dental procedures themselves will continue to be managed by our vendor partners (which vary by line of business and are identified on the MNG), coverage for hospital level of care (facility and anesthesia) associated with dental services will be covered with prior authorization through Point32Health using CPT code 41899 when all criteria on the policy have been met. |
| Evolent criteria
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Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health Together, Tufts Health RITogether | 7/1/2025 | As you likely know, Point32Health has a partnership with Evolent to oversee prior authorization programs for certain services.
Effective July 1, 2025, we’re adopting updates to Evolent’s guidelines for musculoskeletal and interventional pain management, including updates to nerve block criteria to align with industry standard medical practice. |
| Carelon criteria | Harvard Pilgrim Commercial, Tufts Health Direct, Tufts Health Together, Tufts Health RITogether, Tufts Health One Care | 6/15/2025 | As a reminder, Point32Health’s molecular diagnostic testing program is managed through an arrangement with Carelon Medical Benefits Management for certain products.
Effective June 15, 2025, we’re adopting updates to the following Carelon guidelines:
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| Evolent criteria
Magnetic Resonance Elastography (MRE) for Chronic Liver Disease
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Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health Together, Tufts Health RITogether, Tufts Health One Care
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5/1/2025 | Point32Health has retired our Magnetic Resonance Elastography (MRE) for Chronic Liver Disease Medical Necessity Guidelines, and our vendor partner Evolent will now be performing prior authorization review for this service and the associated CPT code 76391.
To request prior authorization, you can contact Evolent online at www.radmd.com or by phone at one of the following numbers, which vary depending on the member’s product:
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| AposTherapy System | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Medicare Preferred | 5/1/2025 | Minor updates made to criteria. |