Updates to Medical Necessity Guidelines (MNG)
|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.
||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.
Director, Provider Relations & Communications
Senior Manager, Provider Communications
Joseph O’Riordan, Susan Panos, Stephen Wong,