Updates to Medical Necessity Guidelines (MNG)
| MNG title | Products affected | Effective date | Summary |
| Surgical Procedures for the Treatment of Obstructive Sleep Apnea | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Public Plans | April 1, 2023 | Updating Harvard Pilgrim’s Obstructive Sleep Apnea Surgeries MNG and Tufts Health Plan’s Uvulopalatopharyngoplasty (UPPP) and Other Procedures for Obstructive Sleep Apnea MNG to more closely align. MNGs will be renamed Surgical Procedures for the Treatment of Obstructive Sleep Apnea. Existing Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea MNGs will be retired, and the InterQual criteria for hypoglossal nerve stimulation will be added to this MNG.
Updates to the Harvard Pilgrim MNG will include:
Updates to the Tufts Health Plan MNG will include:
|
| Hematopoietic Stem-Cell Transplantation (HSCT) | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Public Plans | April 1, 2023 | Prior authorization will be required for Harvard Pilgrim members, which aligns with Tufts Health Plan’s existing policy, and specific clinical coverage criteria for have been added per indication to the Harvard Pilgrim MNG (refer to the updated MNG for the codes requiring prior authorization). New criteria added to Tufts Health Plan MNG for paroxysmal nocturnal hemoglobinuria, thalassemia, and repeat allogeneic stem cell transplant. All limitations removed for:
|
| Oral Formula and Enteral Nutrition
(Harvard Pilgrim and Tuft Health Plan)
|
Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct | April 1, 2023 | New integrated Point32Health MNG. For details on the changes, including prior authorization updates, please refer to the related article in this issue, Obtaining oral formulas. |
| OncoHealth’s Bevacizumab MNG (for Harvard Pilgrim Commercial)
OncoHealth Harvard Pilgrim Medicare Part B Step Therapy MNG Bevacizumab Products MNG
Medicare Part B Step Therapy MNG |
All Point32Health lines of business | Harvard Pilgrim Commercial: April 1, 2023
All other lines of business: Feb. 1, 2023 |
Vegzelma, a biosimilar of Avastin approved by the FDA in September 2022, has been added as a non-preferred drug and now requires prior authorization for all Point32Health lines of business.
Patients are required to have first tried one of the preferred products (Mvasi or Zirabev) before coverage will be approved for Vegzelma. |
| Cochlear Implants | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Public Plans | Feb. 1, 2023 | New integrated Point32Health MNG created as a coverage guideline. Prior authorization is not required. The previous Cochlear Implants Medical Policy specific to Harvard Pilgrim has been retired, and this new integrated MNG now applies for both legacy organizations.
The codes identified on the MNG may be covered when the patient has a diagnosis of bilateral or unilateral hearing loss and the necessary criteria are met. |
| Transcatheter Mitral Valve Repair | Harvard Pilgrim Commercial | Feb. 1, 2023 | New MNG created as a coverage guideline for Harvard Pilgrim Commercial plans, in alignment with the existing Tufts Health Plan MNG. CPT codes 33418, 33419, and 0345T are covered, and prior authorization is not required. |
| OncoHealth Radiation Therapy Review Criteria | Harvard Pilgrim Commercial, Harvard Pilgrim StrideSM (HMO)/(HMO-POS) Medicare Advantage | Feb. 1, 2023 | Minor criteria updates related to Centers for Medicare and Medicaid Services (CMS) National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs).
Keep in mind that Harvard Pilgrim’s Commercial and StrideSM (HMO)/(HMO-POS) Medicare Advantage plans will no longer use OncoHealth for radiation oncology medical management as of April 1, 2023. Refer to this article for more information. |
| Genetic Testing: BRCA1 and BRCA2; Hereditary Breast, Ovarian and Pancreatic Cancer | Tufts Health Plan Commercial | Feb. 1, 2023 | Point32Health MNG developed for Tufts Health Plan Commercial products, in alignment with criteria used by AIM Specialty Health® (our molecular diagnostic testing utilization management vendor for Harvard Pilgrim Commercial plans and Tufts Health Public Plans).
New MNG contains information from Tufts Health Plan’s previous Genetic Testing: BRCA-Related Breast and/or Ovarian Cancer Syndrome MNG. Criteria updated to align with current National Comprehensive Cancer Network guidelines. |
| Genetic Testing: Gene Expression for Cancer of Unknown Primary (CUP) | Tufts Health Plan Commercial | Feb. 1, 2023 | Annual review, minimal changes. CPT code 84999 (Unlisted chemistry procedure [when used to describe a gene expression assay for cancer of unknown origin]) removed from the MNG. Refer to Tufts Health Plan’s Unlisted and Not Otherwise Classified Codes Payment Policy. |
| Preimplantation Genetic Testing | Tufts Health Plan Commercial | Feb. 1, 2023 | MNG title changed from Preimplantation Genetic Diagnosis to Preimplantation Genetic Testing. Removed genetic counseling requirement and added screening for polygenic risk as a coverage limitation for preimplantation genetic testing.
Limitations section refers to Massachusetts and Rhode Island Assisted Reproductive Technology Services MNGs for any applicable limitation related to assisted reproductive technology services. |
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