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)
Visit the Medical Necessity Guidelines page on our Point32Health provider website |
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| MNG Title | Products Affected | Effective Date | Summary |
| Balloon Dilation of the Eustachian Tube | Harvard Pilgrim Commercial | 8/1/2024 | For Harvard Pilgrim Commercial, the CPT codes associated with this MNG (69705 and 69706) will be covered only when they are submitted with an appropriate ICD-10 diagnosis code from the list attached to the updated MNG. |
| Peroral Endoscopic Myotomy for Treatment of
Esophageal Achalasia (POEM) |
Harvard Pilgrim Commercial | 8/1/2024 | For Harvard Pilgrim Commercial, CPT code 43497 (Lower esophageal myotomy, transoral [i.e., peroral endoscopic myotomy]) will be covered only when submitted with the ICD-10 diagnosis code K22.0 (achalasia of cardia). |
| Procedures for the Treatment of Benign Prostatic Hypertrophy | Harvard Pilgrim Commercial, Tufts Health Together, Tufts Health Direct, Tufts Health One Care, Tufts Health RITogether | 8/1/2024 | Point32Health will require prior authorization for the following codes related to the treatment of benign prostatic hypertrophy, and corresponding products:
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| Percutaneous Tibial Nerve Stimulation | 6/1/2024 | Annual review, no changes. | |
| Preimplantation Genetic Testing | Tufts Health Plan Commercial | 6/1/2024 | The following criterion will be added to the MNG:
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| Genetic Testing – Prenatal Diagnosis and Carrier Screening | Tufts Health Plan Commercial | 6/1/2024 | In alignment with Carelon, we’ve updated the MNG to include the following medical necessity criterion specific to expanded carrier screening:
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