| Updates to Medical Necessity Guidelines (MNG) | |||
| MNG Title | Products Affected | Effective Date | Summary |
| Reconstructive and Cosmetic Surgery | Harvard Pilgrim commercial | Feb. 1, 2024 | Prior authorization will be required for CPT code 17380 (Electrolysis epilation). |
| Solid Organ Transplant: Intestinal (Small Bowel, Simultaneous Small Bowel-Liver) and Multivisceral | Tufts Health Plan commercial, Tufts Health Public Plans | Jan. 1, 2024 | The following codes will no longer require prior authorization:
Solid Organ Transplant – Intestinal:
Solid Organ Transplant – Lung:
Solid Organ Transplant – Pancreas:
|
| Continuous Glucose Monitoring Systems: Freestyle and Dexcom Products (Harvard Pilgrim)
Continuous Glucose Monitoring Systems: Freestyle and Dexcom Products (Tufts Health Plan) |
Harvard Pilgrim StrideSM (HMO)/(HMO-POS) Medicare Advantage, Tufts Medicare Preferred, Tufts Health Plan Senior Care Options, Tufts Health Unify | Jan. 1, 2024 | Criteria added for the use of CGMs for hypoglycemia due to a diagnosis other than diabetes mellitus for Tufts Health Unify and Tufts Health Plan SCO.
MNG updated to reflect new preferred product strategy for Jan. 1, 2024. Freestyle and Dexcom products are preferred; any other non-preferred CGM may be covered if there is a clinical rationale for why a Freestyle or Dexcom product is not clinically appropriate for the member, and the non-preferred CGM is covered by Medicare. Prior authorization will be required for HCPCS codes A4238 and E2102. |
| Fertility Services for Harvard Pilgrim Health Care Massachusetts Products (Large Group and Merged Market) | Harvard Pilgrim commercial (Massachusetts only) | Jan. 1, 2024
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New MNG, which outlines coverage for the following services to support inclusive family building for all members, including those across sexual orientation and gender identity spectra and those without coparenting partners or those who do not meet infertility criteria from the Assisted Reproductive Technology Services – Massachusetts Products MNG:
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| Assisted Reproductive Technology Services – Maine Products | Harvard Pilgrim commercial (Maine only) | Jan. 1, 2024
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New MNG, which outlines coverage for Harvard Pilgrim members residing in Maine or with a Maine plan for assisted reproductive technology/infertility services, when the prior authorization criteria specified on the MNG are met.
See article titled “Maine mandates and new coverage” for more information. |
| Upper Limb Prostheses | Harvard Pilgrim commercial (Maine only) | Jan. 1, 2024
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In support of Maine House Bill 1003 (An Act to Improve Outcomes for Persons with Limb Loss), we will cover one additional prosthesis or prosthetic component for recreational purposes when criteria are met for Harvard Pilgrim commercial members under 18 residing in Maine or with Maine plans.
See article titled “Maine mandates and new coverage” for more information. |
| Reconstructive and Cosmetic Surgery (Harvard Pilgrim, Tufts Health Plan) | Harvard Pilgrim commercial, Tufts Health Plan commercial, Tufts Health Public Plans | Jan. 1, 2024 | Minor revisions to criteria language. |
| Noncovered Investigational Services (Harvard Pilgrim, Tufts Health Plan) | Harvard Pilgrim commercial, Tufts Health Plan commercial, Tufts Health Public Plans | Dec. 1, 2023 | Genetic testing for Ehlers-Danlos Syndrome (EDS) in patients with joint hypermobility, skin hyperextensibility, and/or tissue fragility has been removed from the noncovered investigational services list and is now covered for Tufts Health Plan commercial products and Tufts Health Public Plans.
Codes A9628 and A9629 related to Vibrant System (Vibrant Gastro Inc.) for chronic idiopathic constipation have been added and will now deny when billed. |
| Continuous Glucose Monitors and Diabetes Management Devices for Tufts Health Together | Tufts Health Together | Dec. 1, 2023 | In support of MassHealth guidance issued in October 2023, MNG updated with prior authorization criteria for coverage of Omnipod GO. |
| High-Frequency Chest Wall Oscillation Devices (Harvard Pilgrim, Tufts Health Plan) | Harvard Pilgrim commercial, Tufts Health Plan commercial, Tufts Health Public Plans | Dec. 1, 2023 | This MNG is being retired, and prior authorization is no longer required for codes E0483 A7025, or A7026. |
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