Back to Insights and Updates for ProvidersOctober 2024

Point32Health Medical Necessity Guideline updates

All products

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
Genetic and Molecular Diagnostic Testing Tufts Health Plan Commercial 12/1/2024 Prior authorization will be required for CPT code 0473U.
Continuous Glucose Monitoring and Diabetes Management Devices

 

 Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health RITogether, Tufts Health One Care

 

 12/1/2024 Coverage will be added for long-acting basal insulin and revised gestational diabetes criteria.

In addition, prior authorization will be required for the implantable continuous glucose monitor codes 0446T, 0447T, and 0448T.

For Tufts Health One Care, prior authorization will be required for codes A4329 and E2103.

For Tufts Health RITogether, prior authorization will be required for codes A9276, A9277, and A9278.
Continuous Glucose Monitoring Systems: Freestyle and Dexcom Products Tufts Health One Care 12/1/2024 Minor updates to criteria, and prior authorization will be required for codes A4238 and E2102.
Continuous Glucose Monitoring Systems: Freestyle and Dexcom Products

 

 Harvard Pilgrim StrideSM (HMO)/(HMO-POS) Medicare Advantage, Tufts Medicare Preferred, Tufts Health Plan Senior Care Options 10/1/2024 Minor updates to criteria.
Absorbent Products Tufts Health Together, Tufts Health One Care 10/1/2024 Minor updates to criteria, as well as defining indeterminable” incontinence.
Gender Affirming Services Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health RITogether, Tufts Health Together, Tufts Health One Care 10/1/2024 Minor updates to criteria.

 
Genetic Testing: Whole Exome and Whole Genome Sequencing Tufts Health Plan Commercial 10/1/2024 Added epilepsy as a covered indication.
Annual review:

  • Intensity Modulated Radiation Therapy
  • Proton Beam Therapy
  • Stereotactic Radiosurgery and Stereotactic Body Radiotherapy
  • Tumor Treating Fields
  • Pluvicto
  • Breast Pumps
  • Child Care Services for Members enrolled in Tufts Health Plan’s Healthy Birthday Program
  • Donor Breast Milk for Maine Products
  • Genetic Testing – Cell Free DNS Screening for Fetal Trisomy (THP Commercial ONLY)
  • Genetic Testing – Prenatal Diagnosis, Carrier Screening (THP Commercial ONLY)
  • Hysterectomy
  • Fecal Microbial Transplant (FMT) for Clostridium Difficile Infection
  • Monitored Anesthesia Care for Assistance for Gastrointestinal Endoscopic Procedures
  • Solid Organ Transplant – Liver
  • Solid Organ Transplant – Pancreas
  • Solid Organ Transplant – Intestinal
  • Upper Gastrointestinal Endoscopy
  • Video Capsule Endoscopy
 Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Public Plans 10/1/2024 Annual review of a number of MNGs pertaining to radiation oncology, obstetrics and gynecology, and gastrointestinal services.

Minor criteria updates for Intensity Modulated Radiation Therapy MNG, and no changes for the remaining MNGs reviewed.