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 TitleProducts AffectedEffective DateSummary
Lower Limb ProsthesesHarvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health Together, Tufts Health RITogether, Tufts Health One Care 2/1/2026Prior authorization will only be required for microprocessor/complex components of prosthetics, and is no longer required for these standard prosthetic build codes.
Upper Limb ProsthesesHarvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health Together, Tufts Health RITogether, Tufts Health One Care 2/1/2026

Prior authorization will only be required for microprocessor/complex components of prosthetics, and is no longer required for these standard prosthetic build codes.

 

Tufts Medicare Preferred (HMO and PPO) Prior Authorization, Notification, and No Prior Authorization Medical Necessity Guidelines

Tufts Health Senior Care Options Prior Authorization, Notification, and No Prior Authorization Medical Necessity Guidelines

Tufts Medicare Preferred, Tufts Health Plan Senior Care Options2/1/2026

Prior authorization will only be required for  microprocessor/complex components of upper limb prosthetics, and is no longer required for these standard prosthetic build codes.

 

Medicare Noncovered Investigational ServicesTufts Medicare Preferred, Tufts Health Plan Senior Care Options2/1/2026Removed CPT code 27278 from the policy, as we will now cover this code in alignment with CMS’s local coverage determination. 
Noncovered Investigational ServicesTufts Health One Care 2/1/2026Removed CPT codes 27278 and 0080U from the policy, as we will now cover these codes in alignment with CMS’s local coverage determination.
Noncovered Investigational ServicesHarvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health Together, Tufts Health RITogether2/1/2026Bladder EpiCheck test added to the policy to reflect that it is no longer covered. 
Power Wheelchair Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct2/1/2026Removed limitation on “Power seat elevation system, any type,” which now reports to the covered CPT code E2298. 
Implantable Neurostimulators Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health Together, Tufts Health RITogether, Tufts Health One Care2/1/2026

Minor revisions to criteria for sacral nerve stimulators related to urinary retention.

Added criteria for sacral nerve stimulators related to Fecal Incontinence. 

AposTherapy System Tufts Health Plan Commercial, Tufts Health Direct 2/1/2026Removed Tufts Health Plan Commercial and Tufts Health Direct as applicable products for this MNG. 
Non-Emergent Ambulance Transportation for Tufts Medicare Preferred (HMO and PPO)Tufts Medicare Preferred 2/1/2026

Prior authorization is no longer required for hospital-to-SNF transfers. 

We will continue to evaluate prior authorization requirements in the future, and will provide appropriate notice in the event that authorization is reinstated.

Children’s Behavioral Health Initiative – Family Based Intensive Treatment (FIT)Tufts Health Together 1/1/2026Minor criteria changes to align with 1/1/2026 updates to MassHealth criteria. 

Children’s Behavioral Health Initiative In Home Behavioral Services

Children’s Behavioral Health Initiative In-Home Therapy (IHT) Services

Children’s Behavioral Health Initiative Therapeutic Mentoring (TM) for Tufts Health Together

 

Tufts Health Together1/1/2026Minor criteria changes to align with 1/1/2026 updates to MassHealth criteria, and MNGs updated to include references to family based intensive treatment. 
Bariatric SurgeryTufts Health Together, Tufts Health One Care1/1/2026CPT code 43889 now covered with prior authorization.