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 |
| Colonoscopy | Harvard Pilgrim Commercial, Tufts Health Direct | 10/1/2026 | New MNG. CPT codes 45385, 45380, and 45378 are considered medically necessary when submitted with an appropriate ICD-10 diagnosis code, and modifier 33 must be included on preventive colonoscopy claims. The MNG identifies which covered medical conditions are categorized as preventive, diagnostic, or therapeutic. Refer to this article for additional information.
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| Removal of Benign Skin Lesions | Harvard Pilgrim Commercial | 10/1/2026 | The following CPT codes for excision of benign skin lesions will be considered medically necessary only when submitted with certain ICD-10 diagnosis codes specified on the MNG:
(Consistent with Maine regulations, a redlined version of the MNG is posted temporarily.) |
| Carelon Guidelines | Harvard Pilgrim Commercial, Tufts Health Direct, Tufts Health RITogether, Tufts Health One Care | 9/16/2026 | Carelon, the vendor who oversees our genetic and molecular diagnostic testing program, will incorporate criteria updates to the following guidelines:
Notably, the criteria for thrombophilia testing on Carelon’s Genetic Testing for Inherited Conditions Guidelines will be updated to no longer cover the test in patients with venous thromboembolism (VTE) contemplating pregnancy who have a first-degree relative with VTE and a confirmed hereditary thrombophilia.
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Home Health Care Services for Harvard Pilgrim Health Care Commercial (Maine only) Home Health Care Services for Harvard Pilgrim Health Care Commercial, Tufts Health Plan Commercial, and Tufts Health Direct (MA, RI, and NH)
| Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct | 7/1/2026 | New MNG specific to home health care services for Harvard Pilgrim Commercial products in Maine. MNG for Harvard Pilgrim Commercial and Tufts Health Direct (MA, RI, and NH) subsequently updated to remove references to Maine.
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| Inpatient Acute and Post-Acute Levels of Care (Medical/Surgical) | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health Together, Tufts Health RITogether, Tufts Health One Care | 7/1/2026 | MNG updated for additional clarity around utilization management requirements (notification required for acute inpatient admissions; prior authorization required for post-acute levels of care). |
Early Intensive Behavioral Intervention (Tufts Health Together) Early Intensive Behavioral Intervention (Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct) | Tufts Health Together, Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct | 7/1/2026 | New MNG developed specific to Tufts Health Together, with criteria from MassHealth. Down Syndrome added as an applicable diagnosis. Subsequently, references to Tufts Health Together removed from existing MNG for Harvard Pilgrim Commercial, Tufts Health Plan Commercial, and Tufts Health Direct. |
| Reconstructive and Cosmetic Surgery | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health Together, Tufts Health RITogether, Tufts Health One Care | 7/1/2026 | Visit limit for laser treatment of hemangioma and port wine stain and other vascular lesions expanded to allow for six-to-eight visits. (Additional visits will require documentation of medical necessity.) |
| Noncovered Investigational Services | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health Together, Tufts Health RITogether | 7/1/2026 | MNG updated to remove the following prostate biopsy codes, which are now covered without prior authorization retroactively to Jan. 1, 2026:
Previously submitted claims will be automatically reprocessed as appropriate. CPT code 0247U will also be removed from the MNG and covered without prior authorization, effective July 1, 2026. |
Transcranial Magnetic Stimulation (rTMS) Genetic and Molecular Diagnostic Testing Orthognathic Surgery for Severe Oral Maxillofacial Functional Disorders Temporomandibular Joint (TMJ) Disorder Treatment Hysterectomy, Certain Elective Outpatient Habilitative Services for Physical Therapy, Occupational Therapy, and Speech Therapy | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health Together, Tufts Health RITogether, Tufts Health One Care | 7/1/2026 | 2026 InterQual criteria adopted for these MNGs. |