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 |
| Psychological Testing | Tufts Health Direct, Tufts Health Together | 10/1/2024 | Prior authorization will be required for CPT codes 96130 (psychological testing evaluation services [first hour]) and 96131 (psychological testing evaluation services [each additional hour]) for Tufts Health Direct and Tufts Health Together.
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| Assisted Reproductive Technology Services – Massachusetts Products
Assisted Reproductive Technology Services – Maine Products Assisted Reproductive Technology Services – New Hampshire Products Assisted Reproductive Technology Services – Rhode Island Products
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Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct | 10/1/2024 | Minor criteria updates for further clarity.
In addition, prior authorization will be required for CPT code 89272 (extended culture of oocyte[s]/embryo[s], 4–7 Days) for Tufts Health Direct. |
| Transcranial Magnetic Stimulation
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Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health Together, Tufts Health RITogether | 10/1/2024 | Annual review of 2024 InterQual criteria.
Prior authorization will be required for CPT codes 90867, 90868, and 90869 for Tufts Health Direct, Tufts Health Together, and Tufts Health RITogether. |
| Gender Affirming Services
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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 | Criteria updated to note that for transmasculine or gender diverse members requesting surgical chest procedures, hormone therapy is not required. When criteria are met, the following breast/chest surgical procedures to treat gender dysphoria are considered medically necessary:
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| Noncovered Investigational Services
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Tufts Health One Care | 8/1/2024 | A number of codes associated with the following specialties will be newly covered with no prior authorization for Tufts Health One Care, to more closely align with Centers for Medicare and Medicaid Services (CMS) coverage:
For more information, refer to the code list identified on our Noncovered Investigational Services Medical Necessity Guidelines. |
| Lymphedema Surgery
Continuous Glucose Monitors and Diabetes Devices Continuous Glucose Monitors and Diabetes Devices for Tufts Health Together |
Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health Together, Tufts Health RITogether, Tufts Health One Care | 8/1/2024 | Annual review, no changes. |
| Neuropsychological Testing
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Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health Together, Tufts Health RITogether
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8/1/2024 | Annual review of 2024 InterQual criteria, no changes.
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| Bariatric Surgery | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health Together, Tufts Health RITogether, Tufts Health One Care
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8/1/2024 | Annual review of 2024 InterQual criteria, certain 2024 subsets adopted.
Of note, under the 2024 InterQual criteria members of Asian descent are eligible for bariatric surgery at a BMI of 27 in conjunction with metabolic syndrome or diabetes, based on guidance from the American Association for Bariatric Surgery. Tufts Health One care will newly utilize InterQual criteria for prior authorization review. |
| Surgical Procedures for the Treatment of Obstructive Sleep Apnea | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health Together, Tufts Health RITogether, Tufts Health One Care
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8/1/2024 | Criteria updated to align with new FDA guidelines. For adults:
In addition, new dedicated criteria added for coverage of hypoglossal nerve stimulation for members with pediatric down syndrome. |
| Fertility Services for Harvard Pilgrim Health Care Commercial Massachusetts Products (Large Group and Merged Markets) | Harvard Pilgrim Commercial | 8/1/2024 | MNG updated to clarify eligibility and the intent of the benefit. |
| Out-of-Network Coverage at the In-Network Level of Benefits and Continuity of Care (All Plans) | All products | 7/9/2024 | The MNG has been renamed from Out-of-Network Coverage at the In-Network Level of Benefits (All Plans) to Out-of-Network Coverage at the In-Network Level of Benefits and Continuity of Care (All Plans).
Applicability of the MNG has been expanded to include Harvard Pilgrim StrideSM (HMO)/(HMO-POS) Medicare Advantage, Tufts Health Plan Senior Care Options (SCO), and Tufts Medicare Preferred. New criteria language added regarding continuity of care for Tufts Health Together, Tufts Health RITogether, Senior Products, and Dual Eligible Plans, as well as coverage and service area for SCO and Medicare HMO plans. |