The chart below identifies updates to our Medical Necessity Guidelines. For additional details, refer to the Medical Necessity Guidelines page on our Point32Health provider website, where you can find coverage and prior authorization criteria for our Harvard Pilgrim and Tufts Health Plan lines of business.
| Updates to Medical Necessity Guidelines (MNG) | |||
| MNG Title | Products Affected | Effective Date | Summary |
| Carelon medical benefits management program | Harvard Pilgrim Commercial | 3/1/2026 | Prior authorization will be newly required for coverage of a number of codes/services through our medical benefits management program with Carelon. Refer to this document for the full list. |
| Home Health Care | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct | 1/1/2026 | In support of guidance from state regulatory bodies, coverage for CPT code 99501 (Home visit for postnatal assessment and follow-up care) will no longer require prior authorization. As the service is now covered without prior authorization, the code has been removed from the MNG.
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Manual Wheelchairs (Commercial and Tufts Health Direct)
Manual Wheelchairs (Tufts Health Public Plans) | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health Together, Tufts Health RITogether, Tufts Health One Care (HMO D-SNP) | 1/1/2026 | Retiring MNGs and removing prior authorization requirement. |
| Oxygen and Respiratory Therapy Equipment | Tufts Health Direct, Tufts Health Together, Tufts Health RITogether, Tufts Health One Care | 1/1/2026 | Retiring MNG and removing prior authorization requirement. |
| Out-of-Network Coverage at the In-Network Level of Benefits and Continuity of Care (All Plans) | Tufts Health One Care, Tufts Health Plan Senior Care Options | 1/1/2026 | Criteria added to MNG for Tufts Health One Care (HMO D-SNP) and Tufts Health Plan Senior Care Options. |
| Hematopoietic Stem Cell Transplantation | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health Together, Tufts Health RITogether, Tufts Health One Care | 1/1/2026 | Criteria updated to specify that pediatric coverage may be allowed when the member is resistant to tyrosine kinase inhibitors, and to include haploidentical donors as authorized when criteria are met for the following indications:
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| Intraoperative Neurophysiological Monitoring | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health Together, Tufts Health RITogether, Tufts Health One Care | 1/1/2026 | Minor formatting changes. |
| Fecal Microbial Transplant (FMT) for Clostridium Difficile Infection | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health Together, Tufts Health RITogether, Tufts Health One Care | 1/1/2026 | Minor formatting changes and language clarification. In addition, for Uniformed Services Family Health Plan members, in alignment with the current rule for other applicable products, procedure codes G0455 and 44705 will be covered only when they are billed with the ICD-10 diagnosis codes A04.71 or A04.72, as appropriate. |
| Monitored Anesthesia Care for Gastrointestinal Procedures | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health Together, Tufts Health RITogether, Tufts Health One Care | 1/1/2026 | Added anticipated prolonged procedure where therapeutic intervention may be involved as a covered scenario for monitored anesthesia care for upper or lower gastrointestinal endoscopy. |
| AposTherapy System | Tufts Medicare Preferred | 1/1/2026 | Removed Tufts Medicare Preferred as an applicable product for this MNG. |
Non-Covered Home and Community Based Services – Flexible Benefits Tufts Health One Care
Home Accessibility Adaptations
Respite Care for Tufts Health One Care
Long-Term Services and Supports (LTSS) for Tufts Health One Care | Tufts Health One Care | 1/1/2026 | New Non-Covered Home and Community Based Services – Flexible Benefits Tufts Health One Care MNG developed to reflect coverage criteria for a number of home- and community-based services for Tufts Health One Care (HMO D-SNP). As a result, we have removed One Care as an applicable product for the Home Accessibility Adaptations MNG and retired the Respite Care for Tufts Health One Care MNG, and the relevant information pertaining to One Care from these MNGs can be found on the new MNG. In addition, criteria for the following services have been removed from the Long-Term Services and Supports (LTSS) for Tufts Health One Care MNG and can now be found on the Non-Covered Home and Community Based Services – Flexible Benefits Tufts Health One Care MNG:
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| Intensity-Modulated Radiation Therapy (IMRT) | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health Together, Tufts Health RITogether, Tufts Health One Care, Tufts Medicare Preferred, Tufts Health Plan Senior Care Options | 12/31/2025 | We have temporarily retired the Intensity-Modulated Radiation Therapy (IMRT) Medical Necessity Guidelines, as the codes listed as requiring prior authorization on the MNG are being discontinued as of Dec. 31, 2025. As a result, for all products, prior authorization is currently no longer required for IMRT. We will continue to evaluate prior authorization requirements in the future, and will provide appropriate notice in the event that authorization is reinstated. |