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 |
| Medicare Noncovered Investigational Services | Tufts Medicare Preferred, Tufts Health Plan Senior Care Options | 3/1/2026 | In support of guidance from the Centers for Medicare and Medicaid Services, we will now cover these codes pertaining to skin substitutes and bioengineered skin grafts without prior authorization. |
| Applied Behavioral Analysis (ABA) for Commercial Products and Tufts Health Direct | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct | 3/1/2026 | Updated MNG to remove limited evidence designation for members 13-20 and requirement for secondary review, based on age alone. |
| Out-of-Network Coverage at the In-Network Level of Benefits and Continuity of Care (All Plans) | Tufts Health RITogether | 3/1/2026 | MNG updated in an effort to further facilitate seamless transitions of care for new Tufts Health RITogether members. New members who have previously received prior authorization for sickle cell disease gene therapy can continue to receive coverage for related care and prescriptions, and will have access to their same sickle cell disease gene therapy providers until at least one year after receiving their gene therapy infusion. |
| CPT code 30560 (not associated with any MNG) | Harvard Pilgrim Commercial | 3/1/2026 | Prior authorization is no longer required for CPT code 30560 (Lysis intranasal synechia). |