Back to Insights and Updates for ProvidersMarch 2023

Point32Health Medical Necessity Guideline updates

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Updates to Medical Necessity Guidelines (MNG)

MNG Title Products Effective Date Summary
Manual Wheelchairs (Harvard Pilgrim Commercial)

Manual Wheelchairs (Tufts Health Plan Commercial and Direct)

 Harvard Pilgrim Commercial May 1, 2023 In alignment with Tufts Health Plan, Harvard Pilgrim Health Care is adopting InterQual criteria for Commercial prior authorization review, and will draw from the following subsets:

  • Wheelchair Manual, Standard Hemi (low seat)
  • Wheelchair Manual, Lightweight
  • Wheelchair Manual, High Strength Lightweight
  • Wheelchair Manual, Ultra Lightweight
  • Wheelchair Manual, Heavy Duty
  • Wheelchair Manual, Extra Heavy Duty
  • Wheelchair Manual, Adult Size, Includes Tilt in Space

Prior authorization will be required for codes K0002, K0003, K0004, K0005, K0006, K0007, and E1161.
Power Wheelchairs (Harvard Pilgrim Commercial)

Power Wheelchairs (Tufts Health Plan Commercial and Direct)

 Harvard Pilgrim Commercial May 1, 2023 Harvard Pilgrim is adopting Tufts Health Plan’s criteria, and will require prior authorization for the following code sets:

  • K0010-K0014 – Motorized/power wheelchair, Motorized/power wheelchair base
  • K0813-K0864 – Power wheelchair group 1,2 and 3
  • K0890-K0891 – Power wheelchair group 5
  • K0898 – Power wheelchair, not otherwise classified
  • K0899 – Power mobility device, not coded by DME PDAC or does not meet criteria
  • E1002-E1012 – Wheelchair accessory, power seating system
Power Operated Vehicles (Harvard Pilgrim Commercial)

Power Operated Vehicles (Tufts Health Plan Commercial and Direct)

 Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct May 1, 2023 Harvard Pilgrim is adopting Tufts Health Plan’s criteria, and will require prior authorization for codes E1230, K0800, K0801, K0802, and K0812. (Code K0802 will also require prior authorization for Tufts Health Plan Commercial and Tufts Health Direct.)

In addition, codes K0806, K0807, K0808 will no longer be covered for Harvard Pilgrim Commercial members.
Xenpozyme (Harvard Pilgrim Commercial)

Xenpozyme (Harvard Pilgrim StrideSM [HMO]/[HMO-POS] Medicare Advantage)

Xenpozyme (Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health RITogether)

Xenpozyme (Tufts Health Together)

Xenpozyme (Tufts Health Plan SCO, Tufts Medicare Preferred, Tufts Health Unify)

 All products March 1, 2023 New MNG for Xenpozyme (J3490), an enzyme replacement therapy approved by the FDA in August 2022. Prior authorization is required, and the MNG details the coverage criteria, approved indications, limitations, and more.
Vitamin D Screening and Testing Tufts Health Plan Commercial, Tufts Health Public Plans March 1, 2023 Annual review, no changes.
Private Duty Nursing in the Home Tufts Health Plan Commercial March 1, 2023 Annual review, no changes.
Dental Implants Tufts Health Plan Commercial March 1, 2023 Annual review, no changes.
Clinical Review of Dental Services in Medical Benefit Harvard Pilgrim Commercial March 1, 2023 Annual review, no changes.
Dental Procedures Requiring Hospitalization Tufts Health Plan Commercial March 1, 2023 Coverage criteria expanded to include medical conditions resulting in American Society of Anesthesiology physical status classification of Class III or higher.

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