Back to Insights and Updates for ProvidersApril 2023

Point32Health Medical Necessity Guideline Updates

All products

Updates to Medical Necessity Guidelines (MNG)

MNG Title Products Affected Effective Date Summary
Hospice and Palliative Care Services (Harvard Pilgrim Commercial)

Hospice and Palliative Care Services (Tufts Health Plan Commercial, Tufts Health Direct)

Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct June 1, 2023 MNG will utilize InterQual Home Health Care criteria for in-home hospice and palliative care services. (Harvard Pilgrim and Tufts homegrown criteria will remain for inpatient hospice and palliative care.)

Please note that while InterQual criteria will be employed for review of in-home hospice and palliative care services, providers will not be prompted to fill out an InterQual SmartSheet questionnaire when submitting via HealthTrio. You’ll still be able to review the criteria for these services in the InterQual tool, but when submitting an authorization request you will enter your clinical data directly in the provider portal.

It’s important to make sure you’re submitting all the necessary supporting documentation to ensure an efficient utilization management review process and quick turnaround time.

Allergy Testing and Immunotherapy (Harvard Pilgrim Commercial)

Allergy Testing and Immunotherapy (Tufts Health Plan Commercial)

Harvard Pilgrim Commercial, Tufts Health Plan Commercial June 1, 2023 Harvard Pilgrim’s existing Commercial MNG will be expanded to include Tufts Health Plan Commercial.

Prior authorization will not be required, but a medical necessity edit will manage claims. In addition to the existing frequency limit applied to the number of tests that can be covered, the procedure codes on the MNG will only be covered when they are billed with an appropriate corresponding ICD-10 diagnosis code.

Upper Gastrointestinal Endoscopy (Esophagogastroduodenoscopy, EGD) (Harvard Pilgrim Commercial)

Upper Gastrointestinal Endoscopy (Esophagogastroduodenoscopy, EGD) (Tufts Health Plan Commercial and Tufts Health Public Plans)

Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Public Plans June 1, 2023 Harvard Pilgrim’s existing Commercial MNG will be expanded to include Tufts Health Plan Commercial and Tufts Health Public Plans.

Prior authorization will not be required, but a medical necessity edit will manage claims. The procedure codes on the MNG will only be covered when they are billed with an appropriate corresponding ICD-10 diagnosis code. For Tufts Health Plan, this edit is new for all codes on the MNG, and for Harvard Pilgrim it will newly apply for codes 43231 and 43233.

Continuous Glucose Monitoring and Diabetes Management Devices Tufts Health Public Plans June 1, 2023 Prior authorization will be required for codes 95249, A9274, A9276 , A9277, and A9278 for Tufts Health Public Plans members.
Surgical Treatments for Lymphedema and Lipedema (Harvard Pilgrim Commercial)

Surgical Treatments for Lymphedema and Lipedema (Tufts Health Plan Commercial, Tufts Health Public Plans)

Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Public Plans June 1, 2023 New MNG with coverage criteria for
lipectomy or liposuction, vascularized lymph node transplant, and lymphovenous bypass. Prior authorization will be required for CPT codes 15832, 15833, 15836, 15839, 15877, 15878, 15879, 38999.
Continuous Passive Motion (CPM) Device — Extension Beyond 21 Days (Harvard Pilgrim Commercial)

Continuous Passive Motion (CPM) Device — Extension Beyond 21 Days (Tufts Health Plan Commercial, Tufts Health Public Plans)

Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Public Plans June 1, 2023 Existing Tufts Health Plan MNG for Continuous Passive Motion (CPM) Machine – Upper Extremity will be retired, and the Continuous Passive Motion (CPM)
Device — Extension Beyond 21 Days MNG will apply for Harvard Pilgrim and Tufts Commercial Plans and Tufts Health Public Plans. Prior authorization will continue to not be required for CPM devices for the initial 21 days of use; for use beyond 21 days, codes E0935 and E0936 already require prior authorization for Tufts Health Plan and will require prior authorization for Harvard Pilgrim.
Genetic Testing: Prenatal Diagnosis, Carrier Screening Tufts Health Plan Commercial June 1, 2023 Specific in-house criteria removed for a number of testing services, which will be reviewed using InterQual prior authorization criteria as of June 1.

Genetic counseling, while still highly recommended, will no longer be required prior to or during pregnancy for individuals who have an increased chance of having a child with an inherited disorder.

Genetic and Molecular Diagnostic Testing Tufts Health Plan Commercial June 1, 2023 Prior authorization requirement will be reinstated for whole exome sequencing, and InterQual criteria will be used for prior authorization review.

Adding coverage criteria for molecular testing for targeted therapies and duplicate gene testing.

Polygenic risk score testing will be added as a limitation and no longer covered.

CPT codes 0040U, 0111U, 0179U will be covered with prior authorization.

Outpatient Physical Therapy, Occupational Therapy and Speech Therapy Tufts Health Together, Tufts Health RITogether, Tufts Health Unify June 1, 2023 Adopting 2022 InterQual criteria for habilitative and rehabilitative PT/ST/OT.

A number of CPT codes will require prior authorization as of June 1.

Outpatient Rehabilitative Services: Speech Therapy

Outpatient Rehabilitative Services: Occupational Therapy

Outpatient Rehabilitative Services: Physical Therapy

Tufts Health Plan Commercial, Tufts Health Direct June 1, 2023 Adopting 2022 InterQual criteria for habilitative and rehabilitative PT/ST/OT.

A number of CPT codes will require prior authorization for Tufts Health Direct as of June 1.

Outpatient Habilitative Services for Physical Therapy, Occupational Therapy and Speech Therapy Tufts Health Plan Commercial, Tufts Health Direct June 1, 2023 Minor updates to criteria language. A number of codes will require prior authorization for Tufts Health Direct.
Balloon Dilation of the Eustachian Tube (BDET)
(Harvard Pilgrim Commercial)Balloon Dilation of the Eustachian Tube (BDET) (Tufts Health Plan Commercial, Tufts Health Public Plans)
Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Public Plans April 1, 2023 New MNG intended for use as a coverage guideline. Prior authorization is not required.
Peroral Endoscopic Myotomy for Treatment of Esophageal Achalasia (POEM) (Harvard Pilgrim Commercial)

Peroral Endoscopic Myotomy for Treatment of Esophageal Achalasia (POEM) (Tufts Health Plan Commercial, Tufts Health Public Plans)

Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Public Plans April 1, 2023 New MNG intended for use as a coverage guideline. Prior authorization is not required.

CPT code 43497 will be newly covered for Harvard Pilgrim members and will continue to be covered for Tufts Health Plan Commercial and Tufts Health Public Plans members.

Lower Limb Prosthesis (Harvard Pilgrim Commercial)

Lower Limb Prosthesis (Tufts Health Plan Commercial, Tufts Health Public Plans)

Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Public Plans June 1, 2023 Replacement prosthesis authorization criteria language updated to clarify a replacement may be authorized when there is a change in the physiological condition or functional level of the member, which justifies a new prosthesis or replacement part(s), OR there is an irreparable change in the condition of the device, or in a part of the device.

HCPCS code L5970 now requires prior authorization for Tufts Health Public Plans.

Genetic Testing: Cell-Free DNA Screening for Fetal Trisomy Tufts Health Plan Commercial April 1, 2023 MNG name changed from Genetic Testing: Cell-Free DNA Testing for Fetal Trisomy to Genetic Testing: Cell-Free DNA Screening for Fetal Trisomy.

Genetic counseling, while still highly recommended, will no longer be required.

Stereotactic Radiosurgery and Stereotactic Body Radiotherapy Tufts Health Plan Commercial, Tufts Health Public Plans April 1, 2023 Changes to coverage criteria including:

  • Stereotactic radiosurgery is now covered for ocular melanoma, in addition to uveal melanoma
  • Stereotactic radiosurgery is no longer covered for acoustic neroma
  • Patient must have ≤ five metastatic lesions, as opposed to three, for the treatment of oligometastatic disease of extracranial sites with stereotactic body radiation therapy

As a reminder, refer to this article from the February 2023 issue of Insights and Updates for Providers for information about new prior authorization requirements related to stereotactic radiosurgery and stereotactic body radiotherapy.

Cochlear Implants (Harvard Pilgrim Commercial)

Cochlear Implants (Tufts Health Plan Commercial, Tufts Health Direct)

Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct April 1, 2023 Criteria for coverage of cochlear implants for unilateral hearing loss updated to clarify that it’s covered when the patient has normal to near-normal hearing in the contralateral ear or hearing loss that is treatable by hearing aid.
Spevigo (Harvard Pilgrim Commercial)

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

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

Spevigo (Tufts Health Plan Senior Products and Tufts Health Unify)

All products April 1, 2023 Prior authorization required for Spevigo (HCPCS J1747), a novel selective monoclonal antibody indicated for the treatment of generalized pustular psoriasis.
Hemgenix® (etranacogene dezaparvovec-drlb) suspension for injection (Harvard Pilgrim Commercial)

Hemgenix® (etranacogene dezaparvovec-drlb) suspension for injection (Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health RITogether

Hemgenix® (etranacogene dezaparvovec-drlb) suspension for injection (Tufts Health Together)

Hemgenix® (etranacogene dezaparvovec-drlb) suspension for injection (Harvard Pilgrim StrideSM [HMO]/[HMO-POS] Medicare Advantage,

Hemgenix® (etranacogene dezaparvovec-drlb) suspension for injection (Tufts Health Plan Senior Products, Tufts Health Unify)

All products April 1, 2023 New MNG for Hemgenix (J1411), an adeno-associated virus vector-based gene therapy approved by the FDA in November 2022 for the treatment of adults with Hemophilia B.

Prior authorization is required.

OncoHealth’s Imjudo MNG (for Harvard Pilgrim Commercial. See OncoHealth’s Harvard Pilgrim Prior Authorization Policies page for details)

OncoHealth Chemotherapy Review Criteria (Harvard Pilgrim StrideSM [HMO]/[HMO-POS] Medicare Advantage)

Harvard Pilgrim Commercial, Harvard Pilgrim StrideSM (HMO)(HMO-POS) Medicare Advantage April 1, 2023 Prior authorization required for Imjudo (HCPCS C9146), approved by the FDA in November 2022 for the treatment Stage IV (metastatic) non-small cell lung cancer.
OncoHealth’s Elahere MNG (for Harvard Pilgrim Commercial. See OncoHealth’s Harvard Pilgrim Prior Authorization Policies page for details)

 

OncoHealth Chemotherapy Review Criteria (Harvard Pilgrim StrideSM [HMO]/[HMO-POS] Medicare Advantage)

Harvard Pilgrim Commercial, Harvard Pilgrim StrideSM (HMO)(HMO-POS) Medicare Advantage April 1, 2023 Prior authorization required for Elahere (HCPCS C9146), approved by the FDA in November 2022 to treat folate receptor alpha positive, platinum-resistant epithelial ovarian, fallopian tube, or primary peritoneal cancer.
OncoHealth’s Long-Acting Colony Stimulating
Factor Products MNG (for Harvard Pilgrim Commercial)OncoHealth Chemotherapy Review Criteria (Harvard Pilgrim StrideSM [HMO]/[HMO-POS] Medicare Advantage)Long-Acting Colony Stimulating
Factor Products (Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health RITogether)Neutropenia Colony Stimulating Agents – Long Acting (Tufts Health Plan Senior Care Options, Tufts Medicare Preferred, Tufts Health Unify)

OncoHealth Harvard Pilgrim Medicare Part B Step Therapy MNG

Medicare Part B Step Therapy MNG (Tufts Health Plan Senior Care Options, Tufts Medicare Preferred, Tufts Health Unify)

Harvard Pilgrim Commercial, Harvard Pilgrim StrideSM (HMO)/(HMO-POS) Medicare Advantage,Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health RITogether, Tufts Health Plan Senior Care Options, Tufts Medicare Preferred, Tufts Health Unify April 1, 2023 Prior authorization required for Stimufend (a biosimilar of Neulasta)( HCPCS code Q5127) and Rolvedon,(HCPCS J1449) both of which are non-preferred products and were approved by the FDA in September 2022 to treat patients with non-myeloid malignancies receiving myelosuppressive anti-cancer drugs associated with a clinically significant incidence of febrile neutropenia.
Tecvayli (Harvard Pilgrim Commercial)

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

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

Tecvayli (Tufts Health Together)

Tecvayli (Tufts Health Plan Senior Care Options, Tufts Medicare Preferred, Tufts Health Unify

All products April 1, 2023 Prior authorization required for Tecvayli (HCPCS C9148), approved by the FDA in October 2022 for relapsed or refractory multiple myeloma.
OncoHealth’s Lunsumio MNG (for Harvard Pilgrim Commercial. See OncoHealth’s Harvard Pilgrim Prior Authorization Policies page for details)

OncoHealth Chemotherapy Review Criteria (Harvard Pilgrim StrideSM [HMO]/[HMO-POS] Medicare Advantage)

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

Lunsumio (Tufts Health Together)

Lunsumio (Tufts Medicare Preferred, Tufts Senior Care Options, Tufts Health Unify)

All products April 1, 2023 Prior authorization required for Lunsumio (HCPCS J9999), approved by the FDA in December 2022 to treat adult patients with relapsed or refractory follicular lymphoma after two or more lines of systemic therapy.
Skyrizi (Harvard Pilgrim Commercial)

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

Skyrizi (Tufts Health Plan Commercial, Tufts Health Direct)

Skyrizi (Tufts Health RITogether)

Skyrizi (Tufts Medicare Preferred, Tufts Senior Care Options, Tufts Health Unify)

Harvard Pilgrim Commercial, Harvard Pilgrim StrideSM (HMO)/(HMO-POS) Medicare Advantage, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health RITogether, Tufts Medicare Preferred, Tufts Senior Care Options, Tufts Health Unify June 1, 2023 Medical benefit criteria for Skyrizi updated to align with pharmacy benefit criteria, and providers should request authorization through PromptPA.

Prior authorization is now required for Harvard Pilgrim Commercial and Stride.
Skyrizi (HCPCS J2327 released in January 2023), indicated to treat moderate-to-severe plaque psoriasis in adults who are candidates for systemic therapy or phototherapy, active psoriatic arthritis, and moderately to severely active Crohn’s disease under the medical benefit.

Tzield (Harvard Pilgrim Commercial)

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

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

Tzield (Tufts Health Together)

Tzield (Tufts Medicare Preferred, Tufts Senior Care Options, Tufts Health Unify)

All products April 1, 2023 Prior authorization required for Tzield (HCPCS C9149), approved by the FDA in November 2022, indicated to delay the onset of Stage 3 type 1 diabetes in adults and pediatric patients 8 years of age and older with Stage 2 type 1 diabetes.
OncoHealth HPHC Chemotherapy HCPCS J-Codes List Harvard Pilgrim Commercial, Harvard Pilgrim StrideSM (HMO)/HMO-POS) Medicare Advantage April 1, 2023 Prior authorization required for Pedmark (HCPCS J0208), approved by the FDA in September 2022 to reduce the risk of ototoxicity associated with cisplatin in pediatric patients 1 month and older with localized, non-metastatic solid tumors.
OncoHealth HPHC Chemotherapy HCPCS J-Codes List Harvard Pilgrim Commercial, Harvard Pilgrim StrideSM (HMO)/HMO-POS) Medicare Advantage April 1, 2023 Plerixafor (HCPCS J2562) removed from OncoHealth HPHC Chemotherapy HCPCS J-Codes List and now covered with no prior authorization.
Avastin (bevacizumab) for ophthalmic conditions ONLY

 

Harvard Pilgrim Commercial  Jan. 1, 2023 New MNG specific to Avastin (HCPCS J9035) when used for ophthalmic conditions.

Prior authorization is required.

For oncology indications, providers should continue to request authorization through OncoHealth, but for ophthalmic conditions should request Avastin from Harvard Pilgrim directly and refer to the attached MNG.

Xolair (Harvard Pilgrim Commercial)

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

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

Xolair (Tufts Medicare Preferred, Tufts Senior Care Options, Tufts Health Unify)

Harvard Pilgrim Commercial, Harvard Pilgrim StrideSM (HMO)/(HMO-POS) Medicare Advantage, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health RITogether, Tufts Medicare Preferred, Tufts Senior Care Options, Tufts Health Unify April 1, 2023 Xolair (HCPCS J2357) MNG updated for clarification.

  • Limitation added to distinguish medical benefit dosage from pharmacy benefit dosage
  • Xolair 75mg and 150mg prefilled syringes are covered under the member’s prescription drug benefit if Xolair is being self-administered.
Continuous Glucose Monitoring Systems: Freestyle Libre 2 and Dexcom G6 (Harvard Pilgrim StrideSM [HMO]/[HMO-POS] Medicare Advantage)

Continuous Glucose Monitoring Systems – Dexcom G6, Dexcom G7,
and FreeStyle Libre Systems Only (Tufts Medicare Preferred, Tufts Senior Care Options, Tufts Health Unify)

Harvard Pilgrim StrideSM (HMO)/(HMO-POS) Medicare Advantage, Tufts Medicare Preferred, Tufts Senior Care Options, Tufts Health Unify April 16, 2023 Criteria updated to align with CMS’s Glucose Monitors Local Coverage Determination (L33822).

This LCD previously required three or more daily administrations of insulin and that the member be treated with a continuous subcutaneous insulin pump, but now requires that the member be insulin treated and have a history of problematic hypoglycemia in order to be covered.


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