Back to Insights and Updates for ProvidersOctober 2023

Point32Health Medical Necessity Guideline updates

All products

Updates to Medical Necessity Guidelines (MNG)

MNG Title  Products Affected  Effective Date  Summary
New Technology Assessment and Non-Covered Services

Noncovered Investigational Services

Procedures for the Treatment of
Symptomatic Varicose Veins (Harvard Pilgrim, Tufts Health Plan)

 Harvard Pilgrim Health Care commercial, Tufts Health Plan commercial, Tufts Health Public Plans Nov. 1, 2023
  • Polidocanol Endovenous Microfoam (Varithena) will now be covered, and the Sclerotherapy InterQual SmartSheet will be used for prior authorization review
  • VenaSeal cyanoacrylate glue for varicose veins (CPT codes 36482 and 36483) will be covered with prior authorization, and InterQual criteria will be used for review.
  • Endobronchial Valves for advanced COPD (Spiration Valve System and the Zephyr Endobronchial Valve System (CPT codes 31647, 31651, 31648, and 31649) will be covered with no prior authorization
  • Pattern electroretinography (CPT 0509T) and iStent infinite Trabecular Micro-Bypass System for Open-Angle Glaucoma (CPT 0671T) will be added to the non-covered services lists and will not be covered.
Absorbent Products Tufts Health Together, Tufts Health Unify Oct. 1, 2023 The products/codes associated with this MNG will no longer require prior authorization, and the MNG will be maintained for informational purposes.

Minor criteria language updates based on MassHealth guidelines.

Audrey Kleinberg,
Director, Provider Relations & Communications

Annmarie Dadoly,
Senior Manager, Provider Communications

Joseph O’Riordan, Susan Panos, Stephen Wong,
Writers

Kristin Edmonston,
Production Coordinator

Kristina Cicelova,
Graphic Designer