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 |
| Reconstructive and Cosmetic Surgeries
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Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Public Plans | 9/1/2024 | For Tufts Health Direct, Tufts Health Together, and Tufts Health One Care, prior authorization will be required for the following codes:
In addition, for Tufts Health Direct, Tufts Health Together, Tufts Health One Care, and Tufts Health RITogether, the following codes will require prior authorization when submitted with the ICD-10 diagnosis codes L90.5 or L91.0:
For Harvard Pilgrim Commercial products, panniculectomy procedures will no longer be reviewed against InterQual criteria, and will instead be reviewed in accordance with Point32Health’s in-house criteria through our normal utilization management process. |
| Minimally Invasive Procedures for the Treatment of Benign Prostatic Hypertrophy | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health Together, Tufts Health RITogether, Tufts Health One Care | 9/1/2024 | MNG renamed from Procedures for the Treatment of Benign Prostatic Hypertrophy to Minimally Invasive Procedures for the Treatment of Benign Prostatic Hypertrophy.
We will begin covering Waterjet Tissue Ablation (Aquablation) (CPT 0421T, HCPCS C2596) with prior authorization, and the updated MNG outlines clinical coverage criteria. Point32Health in-house criteria will be utilized for all applicable plans, with the exception of Tufts Health One Care, which will be reviewed against the local coverage determination (LCD). For Tufts Health One Care, Point32Health will now use InterQual criteria for Water Vapor Thermal Therapy, as the associated local coverage determination (LCD) has been retired. (Completed InterQual SmartSheets must be sent by fax to 857-304-6304.) |
| Procedures for the Treatment of Symptomatic Varicose Veins
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Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health Together, Tufts Health RITogether, Tufts Health One Care | 9/1/2024 | Prior authorization will be required for the following CPT codes:
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| Custom Fabricated Oral Appliances for Obstructive Sleep Apnea
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Tufts Health RITogether | 9/1/2024 | Prior authorization will be required for HCPCS code E0486 (oral device/appliance used to reduce upper airway collapsibility, adjustable or non-adjustable, custom fabricated, includes fitting and adjustment). |
| Implantable Neurostimulators
Video Capsule Endoscopy Manual Wheelchairs
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Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health Together, Tufts Health RITogether, Tufts Health One Care | 8/1/2024 | MNGs reviewed/updated as part of 2024 InterQual clinical content updates.
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| Blepharoplasty, Upper/Lower Eyelid, and Brow and/or Eyelid Ptosis Repair
Endoscopic Sinus Surgeries Hysterectomy Mobile Outpatient Cardiac Telemetry Orthognathic Surgery Osteogenesis Stimulators Positive Airway Pressure Devices for OSA (Harvard Pilgrim) Positive Airway Pressure Devices for Tufts Health RITogether and Tufts Health One Care Minimally Invasive Procedures for the Treatment of Benign Prostatic Hypertrophy Surgical Procedures for the Treatment of Obstructive Sleep Apnea Inpatient Acute Level of Care (Med/Surg) Temporomandibular Joint Disorder Vertebroplasty and Kyphoplasty Outpatient Pulmonary Rehabilitation (Harvard Pilgrim only) Molecular Diagnostics (Tufts Health Plan Commercial only) Speech Generating Devices (Tufts Health Public Plans only) Outpatient PT OT ST (Tufts Health Plan only) Home Health Care Services |
Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health Together, Tufts Health RITogether, Tufts Health One Care | 7/1/2024 | MNGs reviewed/updated as part of 2024 InterQual clinical content updates.
Minimally Invasive Procedures for the Treatment of Benign Prostatic Hypertrophy:
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| Behavioral Health Inpatient and 24-Hour Level of Care Determinations | Tufts Medicare Preferred, Tufts Health Plan Senior Care Options | 7/1/2024 | The applicability of this coverage guideline, which is intended to document existing notification processes and requirements, has been expanded to include the Tufts Medicare Preferred and Tufts Health Plan Senior Care Options lines of business. |
| Behavioral Health Level of Care for Non-24 Hour/Intermediate/Diversionary Services | Tufts Medicare Preferred | 7/1/2024 | Coverage guideline updated to clarify that partial hospitalization services require notification in accordance with InterQual Medicare Behavioral Health Criteria, which consists of CMS national coverage determinations (NCDs)/ local coverage determinations (LCDs) for Tufts Medicare Preferred. |
| Positive Airway Pressure Devices for Tufts Health RITogether and One Care
Positive Airway Pressure Devices for Sleep Apnea Sleep Studies for Tufts Health RITogether |
Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health Together, Tufts Health RITogether, Tufts Health One Care | 7/1/2024 | Annual review of sleep-related MNGs, no changes. |
| Allergy Testing and Immunotherapy | Harvard Pilgrim Commercial, Tufts Health Plan Commercial | 7/1/2024 | Allergen Immunotherapy criteria updated with clarifications related to immunotherapy for environmental allergens and immunotherapy connected to a diagnosis of systemic reaction to an insect sting for patients with specific IgE to venom allergens. |
| Reconstructive and Cosmetic Surgeries | All products | 7/1/2024 | Harvard Pilgrim and Tufts Health Plan Commercial, and all Tufts Health Public Plans:
Updates to criteria and notes, including but not limited to language related to
All products: Addition of note clarifying that staged procedures with liposuction combined with excess skin removal that have the potential to change or improve appearance without significantly improving physiological function are considered cosmetic in nature and may be excluded from coverage. |
| Tufts Health One Care Prior Authorization and Inpatient Notification List
Tufts Health Plan Senior Care Options Prior Authorization and Inpatient Notification List Tufts Health Medicare Preferred (HMO and PPO) Prior Authorization and Inpatient Notification List |
Harvard Pilgrim StrideSM (HMO)/(HMO-POS) Medicare Advantage, Tufts Health Plan Senior Care Options, Tufts Health Medicare Preferred, Tufts Health One Care
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7/1/2024 | Newly created Prior Authorization and Inpatient Notification Lists for Harvard Pilgrim StrideSM (HMO)/(HMO-POS) Medicare Advantage and Tufts Health One Care, which outline services requiring prior authorization and notification in one streamlined location for quick reference.
For Tufts Health Plan SCO, previously separate Prior Authorization List and Notification List combined into one comprehensive document. Updated format of existing Medicare Preferred (HMO and PPO) Prior Authorization and Inpatient Notification List. |