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 |
| Upper Gastrointestinal Endoscopy (Esophagogastroduodenoscopy, EGD) | Harvard Pilgrim Commercial, Tufts Health Together, Tufts Health RITogether, Tufts Health Direct, Tufts Health One Care, Tufts Medicare Preferred, Tufts Health Plan Senior Care Options | 6/1/2026 | MNG updated to specify that CPT code 43249 (for esophageal dilation procedures using an endoscope) will be covered without prior authorization only when submitted with an appropriate ICD-10 diagnosis code. |
| Foot Reconstruction Procedures | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct | 6/1/2026 | New MNG outlining prior authorization requirements and criteria for foot reconstruction procedures. Will utilize the following InterQual criteria subsets:
Prior authorization will be required for CPT codes 28308, 28310, 28298, and 28750. (Consistent with Maine regulations, a redlined version of the MNG is posted temporarily.) |
| Therapeutic Apheresis | Harvard Pilgrim Commercial, Tufts Health Direct | 6/1/2026 | New MNG outlining medical necessity criteria for therapeutic apheresis. CPT codes 36514 and 36516 will be covered only when submitted with an appropriate ICD-10 code. (Consistent with Maine regulations, a redlined version of the MNG is posted temporarily.)
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| Gender Affirming Services | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health Together, Tufts Health RITogether, Tufts Health One Care | 6/1/2026 | Prior authorization will be required for the following CPT codes when they are submitted with a diagnosis of gender dysphoria:
(Consistent with Maine regulations, a redlined version of the MNG is posted temporarily.)
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Tufts Medicare Preferred (HMO and PPO) Prior Authorization, Notification, and No Prior Authorization Medical Necessity Guidelines
Tufts Health Plan Senior Care Options Prior Authorization, Notification, and No Prior Authorization Medical Necessity Guidelines | Tufts Medicare Preferred, Tufts Health Plan Senior Care Options | 6/1/2026 | Prior authorization will be required for the following codes/services: Incontinence Devices (CMS NCD 230.10)
Sacral Nerve Stimulation for Urinary Incontinence (CMS NCD 230.18)
Sacral Nerve Stimulation for Fecal Incontinence (CMS Article A53359)
Osteogenesis Stimulators CMS LCD L33796 and Article A52513)
Septoplasty (CMS LCD L39051 and Article A58774)
FoundationOne® Liquid CDx (CMS LCA A5777)
Lower Limb Prostheses (CMS LCD L33787 and Article A52496)
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| Long Term Supports and Services for Tufts Health One Care | Tufts Health One Care | 4/1/2026 | MNG updated to follow MassHealth’s guidance for interim prior authorization. For the following code and modifier combinations, temporary authorization may be granted for a period of 60 calendar days and automatically adjudicated based on the provider’s assessment of the member’s needs. This temporary authorization allows for services to be delivered while required assessments are completed.
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Tufts Health Together Prior Authorization, Notification, and No Prior Authorization Medical Necessity Guidelines
Tufts Health RITogether Prior Authorization, Notification, and No Prior Authorization Medical Necessity Guidelines | Tufts Health Together, Tufts Health RITogether | 4/1/2026 | New MNGs developed to comprehensively document existing prior authorization requirements. |
| Applied Behavior Analysis (ABA) for Tufts Health Together | Tufts Health Together | 1/1/2026 | Updated criteria in alignment with MassHealth. |