Back to Insights and Updates for ProvidersSeptember 2023

Point32Health Medical Necessity Guideline updates

All products

MNG Title Products Affected Effective Date Summary
Fractional Flow Reserve CT (FFRCT) – NIA Harvard Pilgrim commercial, Tufts Health Plan commercial, Tufts Health Public Plans Nov. 1, 2023 CPT codes 0501T, 0502T, 0503T, and 0504T will be covered, and prior authorization will be required through National Imaging Associates.
Solid Organ Transplant: Pancreatic Kidney Transplant, Pancreas Transplant, Pancreas Islet Cell Transplant (Harvard Pilgrim)

Solid Organ Transplant: Pancreatic Kidney Transplant, Pancreas Transplant, Pancreas Islet Cell Transplant (Tufts Health Plan)

 Harvard Pilgrim commercial, Tufts Health Plan commercial, Tufts Health Public Plans Nov. 1, 2023 Some coverage criteria language updates regarding smoking cessation, alcohol use disorder, and substance use disorder.

In addition, codes 0584T, 0585T, and 0586T will require prior authorization for Harvard Pilgrim commercial (prior authorization already required for Tufts Health Plan commercial and Public Plans).
New Technology Assessment and Non-Covered Services (Harvard Pilgrim)

Noncovered Investigational Services (Tufts Health Plan)

 Harvard Pilgrim commercial, Tufts Health Plan commercial, Tufts Health Public Plans Nov. 1, 2023 A number of codes related to red blood cell antigen testing have been added to the non-covered lists and will no longer be covered.
Solid Organ Transplant: Intestinal (Small Bowel, Simultaneous Small Bowel-Liver) and Multivisceral (Harvard Pilgrim)

Solid Organ Transplants: Heart (Harvard Pilgrim)

Solid Organ Transplants: Kidney (Harvard Pilgrim)

Solid Organ Transplants: Liver (Harvard Pilgrim)

Solid Organ Transplants: Lung (Harvard Pilgrim)

Solid Organ Transplant: Intestinal (Small Bowel, Simultaneous Small Bowel-Liver) and Multivisceral (Tufts Health Plan)

Solid Organ Transplants: Heart (Tufts Health Plan)

Solid Organ Transplants: Kidney (Tufts Health Plan)

Solid Organ Transplants: Liver (Tufts Health Plan)

Solid Organ Transplants: Lung (Tufts Health Plan)

 Harvard Pilgrim commercial, Tufts Health Plan commercial, Tufts Health Public Plans Sept. 1, 2023 Some coverage criteria language updates regarding smoking cessation, inhaled substance use, alcohol use disorder, and substance use disorder, as applicable.
Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI) (Harvard Pilgrim)

Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI) (Tufts Health Plan)

 Harvard Pilgrim commercial, Tufts Health Plan commercial, Tufts Health Public Plans Sept. 1, 2023 Removing coverage limitations from the following services, as they are considered medically necessary and may be covered when all applicable criteria are met:

  • B-scan
  • Fundus photography with interpretation and report
  • Ophthalmoscopy extended with retinal drawings with interpretation and report initial
  • Subsequent ophthalmoscopy
Assisted Reproductive Technology Services – Massachusetts Products (Harvard Pilgrim)

Assisted Reproductive Technology Services – Massachusetts Products (Tufts Health Plan)

Assisted Reproductive Technology Services – New Hampshire Products (Harvard Pilgrim)

Assisted Reproductive Technology Services – Rhode Island Products (Tufts Health Plan)

 Harvard Pilgrim commercial, Tufts Health Plan commercial, and Tufts Health Direct Sept. 1, 2023 Removed low oocyte yield criteria for ICSI, clarified assisted hatching criteria, and added the following language to the Limitations section for clarity purposes:

  • ART/fertility services when clinical documentation indicates a member or member’s partner has active or uncontrolled alcohol use disorder or substance use disorder. Results of serum or urine drug screening may be requested before ART services are authorized
Breast Cancer Gene Expression Tests Tufts Health Plan commercial Sept. 1, 2023 MNG title changed from Breast Cancer Index to Breast Cancer Gene Expression Tests.

The EndoPredict and Prosigna BCE tests are now covered, and prior authorization is required.
Cardiovascular Disease Risk Tests (Harvard Pilgrim)

Cardiovascular Disease Risk Tests (Tufts Health Plan)

 Harvard Pilgrim commercial, Tufts Health Plan commercial, Tufts Health Public Plans July 6, 2023 Integrated Point32Health MNG.

Prior authorization is not required, and the MNG is intended as a coverage guideline to offer guidance on medical necessity for cardiovascular disease risk tests.

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