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 |
| Spine and interventional pain management through vendor partner Evolent | Tufts Medicare Preferred | 10/1/2025 | Refer to article in this issue for details on changes in prior authorization requirements for spine and interventional pain management for the products noted. Updates reflected in the Prior Authorization, Notification, and No Prior Authorization Medical Necessity Guidelines for Tufts Health Senior Care Options and Tufts Medicare Preferred. |
| Spine and interventional pain management through vendor partner Evolent | Tufts Health Senior Care Options | 10/1/2025 | Removing prior authorization requirement from CPT codes 22800, 22802, 22808, 22810, and 22812. |
| Clinical Review of Dental Services in the Medical Benefit | Harvard Pilgrim Commercial | 8/1/2025 | Updated to clarify that anesthesia and associated facility changes may not be considered medically necessary if the primary procedure is not covered by the Plan. |
| Hospice and Palliative Care Services | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct | 8/1/2025 | Minor update to criteria for respite care.
In addition, we’ve developed an integrated Point32Health Payment Policy for Hospice Care, which has replaced our previous legacy Harvard Pilgrim and Tufts Health Plan policies. |
| Magnetic resonance Guided Focused Ultrasound | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Together, Tufts Health RITogether, Tufts Health Direct | 8/1/2025 | Updates to the clinical guideline coverage criteria. |
| Non-covered Investigational Services (NCIS) | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Together, Tufts Health RITogether, Tufts Health Direct, Tufts Health One Care | 8/1/2025 | Addition of:
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| Non-emergency Medical Transportation (Ground/air) | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Together, Tufts Health RITogether, Tufts Health One Care, Tufts Health Direct | 8/1/2025 | Criteria updates. Including noting that for Tufts RITogether, non-emergent ambulance services provided to a member during an inpatient/outpatient admission are included as part of the facility reimbursement rate and should be billed to the facility. |
| Surgical Procedures for the Treatment of Obstructive Sleep Apnea | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Together, Tufts Health RITogether, Tufts Health Direct, Tufts Health One Care | 8/1/2025 | Minor criteria update. |
| Tonic Motor Activation for the Treatment of Restless Leg Syndrome | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Together, Tufts Health RITogether, Tufts Health Direct, Tufts Health One Care, Tufts Health Senior Care Options, Tufts Medicare Preferred | 8/1/2025 | New MNG. HCPCS codes E0743 (external lower extremity nerve stimulator) and A4544 (electrode for external lower extremity nerve stimulator for restless leg syndrome) now covered with prior authorization. |