Updates to Medical Necessity Guidelines (MNG)
| MNG Title | Products Affected | Effective Date | Summary |
| New Technology Assessment and Non-Covered Services | Harvard Pilgrim commercial | Oct. 1, 2023 | List of noncovered/investigational services will be updated to reflect that codes Q2026 (Injection, Radiesse, 0.1 ml) and C1878 (Material for vocal cord medialization, synthetic [implantable]) will be considered investigational and no longer covered, except when billed with the ICD-10 diagnosis codes J38.01 or J38.02. |
| Gender Affirming Services (Harvard Pilgrim)
Gender Affirming Services (Tufts Health Plan) |
Harvard Pilgrim commercial, Tufts Health Plan commercial, Tufts Health Public Plans | Oct. 1, 2023 | Criteria changes to align with updates to World Professional Association for Transgender Health (WPATH) standards of care.
Codes 57295, 57296, and 57426 will no longer require prior authorization. Prior authorization will be required for the following CPT codes: 55899, 58999, 14301, 14302, 15773, 15774, 15877, 15878, 15879, 56620, 53410, 54300, 56810. Codes 15824, 15826, and 15828 will no longer be covered. |
| Genetic Testing Prenatal Diagnosis Carrier Screening | Tufts Health Plan commercial | Oct. 1, 2023 | Criteria updates related to targeted carrier screening and expanded carrier screening. |
| Surgical Treatments for Lymphedema and Lipedema (Harvard Pilgrim)
Surgical Treatments for Lymphedema and Lipedema (Tufts Health Plan) |
Harvard Pilgrim commercial, Tufts Health Plan commercial, Tufts Health Public Plans | Oct. 1, 2023 | Bioimpedance spectroscopy will no longer be covered as an option to diagnose lymphedema. |
| Respite Care for Tufts Health Unify | Tufts Health Unify | Oct. 1, 2023 | New MNG outlining criteria for respite care services, in alignment with the criteria from MassHealth’s “130 CMR 630.00: Home- and community-based services waiver services.”
Prior authorization will be required for the codes H0045, T1005, S5150, and S5151. |
| Lumbar Artificial Disc Replacement – Single level (NIA) | Harvard Pilgrim Health Care commercial, Harvard Pilgrim Medicare Advantage | Sept. 1, 2023 | Will cover 22857, 22862, and 22865 with prior authorization via NIA. Notice provided in April newsletter, and implementation was delayed per June newsletter notification. |
| Lumbar Artificial Disc Replacement – Multiple levels (NIA) | Harvard Pilgrim Health Care commercial, Harvard Pilgrim Medicare Advantage | Sept. 1, 2023 | Will cover 22860, 0164T, and 0165T with prior authorization via NIA. Notice provided in April newsletter, and implementation was delayed per June newsletter notification. |
| Genetic and Molecular Diagnostic Testing | Tufts Health Plan commercial | Aug. 1, 2023 | Adding coverage criteria for liquid biopsy testing (testing of circulating tumor DNA). |
| Guardant360 CDx | Tufts Health Plan commercial | Aug. 1, 2023 | Guardant360 CDx testing is now covered in the initial diagnostic setting for patients with breast cancer. |
| Continuous Glucose Monitoring and Diabetes Management Devices for Tufts Health Together | Tufts Health Together | Aug. 1, 2023 | MNG name changed from Continuous Subcutaneous Insulin
Delivery Devices for Tufts Health Together to Continuous Glucose Monitoring and Diabetes Management Devices for Tufts Health Together. In alignment with updates from MassHealth, criteria added for continuous glucose monitoring devices. |
| Genetic and Molecular Diagnostic Testing for Tufts Health Direct, Tufts Health Together, Tufts Health RITogether, Tufts Health Unify | Tufts Health Direct, Tufts Health Together, Tufts Health RITogether, Tufts Health Unify | Aug. 1, 2023 | Prior authorization no longer required for CPT codes 81267 and 81268. |
| Tumor Treating Fields (Harvard Pilgrim)
Tumor Treating Fields (Tufts Health Plan) |
Harvard Pilgrim commercial, Tufts Health Plan commercial, Tufts Health Public Plans | Aug. 1, 2023 | Added the following as a covered indication: adult member with unresectable, locally advanced or metastatic, malignant pleural mesothelioma to be used concurrently with pemetrexed and platinum-based chemotherapy. |
| Stereotactic Radiosurgery and Stereotactic Body Radiotherapy (Harvard Pilgrim)
Stereotactic Radiosurgery and Stereotactic Body Radiotherapy (Tufts Health Plan) |
Harvard Pilgrim commercial, Tufts Health Plan commercial, Tufts Health Public Plans | Aug. 1, 2023 | The following indication will now be covered: Noninvasive cardiac radioablation using stereotactic radiotherapy for the treatment of ventricular tachycardia. |
| Proton Beam Therapy (Harvard Pilgrim)
Proton Beam Therapy (Tufts Health Plan) |
Harvard Pilgrim commercial, Tufts Health Plan commercial, Tufts Health Public Plans | Aug. 1, 2023 | MNG updated to clarify that simultaneous use of proton beam therapy and intensity-modulated radiation therapy is considered non-covered/investigational for any diagnosis. In addition, the following is now covered: melanoma of the uveal tract (iris, choroid, or ciliary body) with no evidence of metastasis or extra-scleral extension. |
| Intensity Modulated Radiation Therapy (Harvard Pilgrim)
Intensity Modulated Radiation Therapy (Tufts Health Plan) |
Harvard Pilgrim commercial, Tufts Health Plan commercial, Tufts Health Public Plans | Aug. 1, 2023 | MNG updated to clarify that simultaneous use of proton beam therapy and intensity-modulated radiation therapy is considered non-covered/investigational for any diagnosis. |
| UVB Home Units for Skin Disease (Harvard Pilgrim)
UVB Home Units for Skin Disease (Tufts Health Plan) |
Harvard Pilgrim commercial, Tufts Health Plan commercial, Tufts Health Public Plans | Aug. 1, 2023 | Prior authorization no longer required for codes E0691, E0692, E0693, and E0694. |
| Continuous Passive Motion Device – Extension Beyond 21 Days (Harvard Pilgrim)
Continuous Paszsive Motion Device – Extension Beyond 21 Days (Tufts Health Plan) |
Harvard Pilgrim commercial, Tufts Health Plan commercial, Tufts Health Public Plans | Aug. 1, 2023 | Prior authorization no longer required for codes E0935 and E0936, and the Continuous Passive Motion Device – Extension Beyond 21 Days MNGs will be retired. |
| COVID-19 Monoclonal Antibody Therapy (Harvard Pilgrim)
COVID-19 Monoclonal Antibody Therapy (Tufts Health Plan) |
Harvard Pilgrim commercial, Tufts Health Plan commercial, Tufts Health Public Plans | Aug. 1, 2023 | Criteria on the MNG updated to reflect current emergency use authorizations from the FDA. |
| Implantable Neurostimulators (Harvard Pilgrim)
Implantable Neurostimulators (Tufts Health Plan) |
Harvard Pilgrim commercial, Tufts Health Plan commercial, Tufts Health Public Plans | Aug. 1, 2023 | The following codes no longer require prior authorization: 95961, 95970, 95971, 95972, 95980, 95981, and 95982. |
| Continuous Glucose Monitoring and Diabetes Management Devices (Harvard Pilgrim)
Continuous Glucose Monitoring and Diabetes Management Devices (Tufts Health Plan)
|
Harvard Pilgrim commercial, Tufts Health Plan commercial, Tufts Health Public Plans (with the exception of Tufts Health Together) | Aug. 1, 2023 | Added clarifying language around CGM access via DME providers or pharmacy.
Prior authorization no longer requires for CPT code 95249. |
| Elahere OncoHealth (Harvard Pilgrim Commercial) | Harvard Pilgrim commercial | Aug. 1, 2023 | Removed step through bevacizumab when used to treat epithelial ovarian, fallopian tube, or primary peritoneal cancer. Elahere will now be a first line treatment. |
| Syfovre (Tufts Health Plan commercial, Tufts Health Direct, Tufts Health RITogether)
Syfovre (Tufts Medicare Preferred, Tufts Health Plan SCO, Tufts Health Unify) Syfovre (Harvard Pilgrim commercial Syfovre (Harvard Pilgrim Stride) |
Harvard Pilgrim StrideSM (HMO)(HMO-POS) Medicare Advantage, Harvard Pilgrim Commercial, Tufts Health Plan commercial, Tufts Health Direct, Tufts Health RITogether, Tufts Health Plan Senior Products, Tufts Health Unify | Aug. 1, 2023 | Prior authorization now required for Syfovre (HCPCS code C9151), approved by the FDA in February 2023 for Treatment of geographic atrophy (GA) secondary to age-related macular degeneration. |
| Leqmebi (Tufts Health Plan commercial, Tufts Health Direct, Tufts Health RITogether, Tufts Health Together)
Leqembi (Tufts Medicare Preferred, Tufts Health Plan SCO, Tufts Health Unify) Leqembi (Harvard Pilgrim commercial Leqembi (Harvard Pilgrim Stride) |
Harvard Pilgrim StrideSM (HMO)(HMO-POS) Medicare Advantage, Harvard Pilgrim Commercial, Tufts Health Plan commercial, Tufts Health Together, Tufts Health Direct, Tufts Health RITogether, Tufts Health Plan Senior Products, Tufts Health Unify | July 11, 2023 | Prior authorization now required for Leqembi (HCPCS code J3490), approved by the FDA in July 2023 for the treatment of Alzheimer’s disease. |
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