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)
To view these guidelines, visit the Medical Necessity Guidelines page on our Point32Health provider website |
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| MNG Title | Products Affected | Effective Date | Summary |
| Home Health Care Services | Harvard Pilgrim Commercial, Tufts Health Plan Commercial | 4/12/2024 | Skilled services provided in the home will no longer require prior authorization for the first 30 days of service, but rather will require notification. After the initial 30 days, prior authorization will be required for continuation of coverage.
Refer to this article for more information. |
| Non-Emergency Medical Transportation (Air and Ground)
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Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health Together, Tufts Health RITogether, Tufts Health One Care | 6/1/2024 | New integrated Point32Health MNG, which will replace the following existing Harvard Pilgrim and Tufts Health Plan MNGs: Non-Emergency Medical Transportation (Air), Non-Emergency Medical Transportation (Ground), and Medical Transportation.
For Harvard Pilgrim members, we are expanding the list of origin and destination modifier combinations not requiring prior authorization. For Tufts Health Plan, HCPCS codes S9960 and S9961 will no longer be covered. Refer to this article for more information. |
| Reconstructive and Cosmetic Surgery | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Public Plans | 4/1/2024 | Prior authorization/coverage criteria specific to procedures for the treatment of lipedema (CPT 15878 and 15879) added to the MNG. |
| Surgical Procedures for Lymphedema | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Public Plans | 4/1/2024 | Surgical Treatments for Lymphedema and Lipedema MNG renamed “Surgical Procedures for Lymphedema,” as this MNG now outlines coverage criteria for Limb Debulking Procedures only, in light of the above-referenced change to the Reconstructive and Cosmetic Surgery MNG.
Removed coverage limitation on liposuction for lipedema when performed for cosmetic purposes. |
| Balloon Dilation of the Eustachian Tube
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Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Public Plans | 4/1/2024 | Minor criteria updates. |
| Bariatric Surgery
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Tufts Health Together, Tufts Health One Care | 4/1/2024 | MNG updated with clarification that bariatric surgery is covered for Tufts Health Together members when performed at facilities that are either accredited by the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP), a joint program of the American College of Surgeons and the American Society for Metabolic and Bariatric Surgery, or have waiver status from MassHealth. You can find a listing of eligible hospitals and facilities here.
Tufts Health One Care will now use MassHealth criteria for review, as opposed to the formerly utilized CMS criteria. |
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Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Public Plans | 4/1/2024 | Annual review of MNGs associated with the ENT and Radiology specialties (including NIA’s 2024 Clinical Guidelines), with no changes.
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