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 |
| Continuous Glucose Monitoring | Tufts Health RITogether, Tufts Health One Care, Tufts Health Direct | 9/1/2025 | Prior authorization will be required for code A4238. This aligns with current coverage for Commercial products in which A4238 requires prior authorization. |
| Dental Procedures Requiring Hospital/Facility-Based Care | Tufts Health One Care | 9/1/2025 | New MNG related to dental procedures performed under sedation or general anesthesia in an acute care inpatient facility or ambulatory surgical setting. Prior authorization is required for code 41899. |
| Family-based Intensive Treatment | Tufts Health Together | 9/1/2025 | Notification required and if services continue after 42 days prior authorization is required for HCPCS code H0046-HT. New MNG provides details on coverage for family-based intensive treatment including in-home therapy, mobile crisis intervention, and family support and training. |
| Intravitreal Injections and Corticosteroid Implants for Ophthalmic Conditions | Harvard Pilgrim Health Care Commercial, Tufts Health Plan Commercial, Tufts Health RITogether, Tufts Health Together, Tufts Health One Care, Tufts Health Direct, Tufts Health Senior Care Options, Tufts Medicare Preferred | 9/1/2025 | New MNG outlining coverage of intravitreal injections and corticosteroid implant for ophthalmic conditions, when billed with appropriate diagnosis codes. Prior authorization will not be required. |
| Noncovered Investigational Services | Harvard Pilgrim Commercial | 9/1/2025 | CPT code 93356 (myocardial strain imaging with speckle tracking) will no longer be covered for Harvard Pilgrim Commercial members. |
| Upper Gastrointestinal Endoscopy | Tufts Health Senior Care Options, Tufts Health Medicare Preferred | 9/1/2025 | New MNG for the products noted outlining coverage of Upper GI endoscopy when billed with the appropriate diagnosis code. Prior authorization will not be required. |
| Gender Affirming Services | Harvard Pilgrim Health Care Commercial, Tufts Health Plan Commercial, Tufts Health Together, Tufts Health RITogether, Tufts Health One Care, Tufts Health Direct | 7/1/2025 | Criteria clarified to note that hair removal from the skin by laser or electrolysis needed in conjunction with planned gender affirming surgical services is considered medically necessary. |
| Implantable Neurostimulators | Harvard Pilgrim Health Care Commercial, Tufts Health Plan Commercial, Tufts Health Together, Tufts Health RITogether, Tufts Health One Care, Tufts Health Direct | 7/1/2025 | Allows coverage of code 61889 with prior authorization. Codes 61891 and 61892 are being removed from the non-covered services list and will be covered without authorization. |
| Percutaneous Tibial Nerve Stimulation | Harvard Pilgrim Health Care Commercial, Tufts Health Plan Commercial, Tufts Health RITogether, Tufts Health Together, Tufts Health One Care, Tufts Health Direct | 7/1/2025 | Minor language updates made for clarification. |
| Respite for Children for Tufts Health RITogether | Tufts Health RITogether | 7/1/12025 | Updated to reflect Rhode Island guidance that families of children under age 21 who meet an institutional level of care criteria are eligible for at least 100 hours of respite services. |