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 |
| Noncovered Investigational Services | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health Together, Tufts Health RITogether, Tufts Health One Care | 5/1/2026 | CPT code 1019T (Lymphovenous bypass, including robotic assistance, when performed, per extremity) removed from Noncovered Investigational Services (NCIS) MNG and now covered with prior authorization for all applicable lines of business. In addition, CPT codes 0786T, 0787T, 0788T, and 0789T removed from NCIS and covered without prior authorization for One Care only. |
| Evolent Advanced Imaging Guidelines | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health Together, Tufts Health RITogether, Tufts Health One Care | 5/1/2026 | Adopted Evolent’s 2026 Advanced Imaging Guidelines. CPT codes 0742T, 70473, and 70472 will now be covered when prior authorization is obtained through Evolent. |
| Blepharoplasty, Upper/Limb Eyelid, Brow Ptosis Repair, Upper Eyelid Blepharoptosis Repair | Tufts Health Direct | 5/1/2026 | Prior authorization is now required for coverage of CPT codes 15820 and 15821 |
| Surgical Procedures for the Treatment of Obstructive Sleep Apnea | Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health Together, Tufts Health RITogether | 5/1/2026 | Prior authorization is now required for coverage of the hypoglossal nerve stimulation CPT codes C8007 and C8011, which were newly released by the American Medical Association on Jan. 1, 2026. |
| Children’s Behavioral Health Initiative Family-based Intensive Treatment (FIT) | Tufts Health Together | 5/1/2026 | MNG pertaining to MassHealth’s CBHI intensive hospital diversion (IHD) program retired, as the program was phased out and replaced by Family Intensive Treatment (FIT). |