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 |
Home Health Care Services for Tufts Health Together Home Health Care Services for Tufts Health RITogether and Tufts Health One Care
| Tufts Health Together, Tufts Health RITogether, Tufts Health One Care | 10/1/2026 | New MNG specific to Home Health Care Services for Tufts Health Together with updated prior authorization requirements and criteria. Subsequent update to existing MNG for Tufts Health RITogether and Tufts Health One Care to remove references to Tufts Health Together, as there is now a separate MNG specific to that line of business. Refer to this article for more information. |
| Long Term Supports and Services (LTSS) for Tufts Health One Care | Tufts Health One Care | 10/1/2026 | Code T1019 will be added to the MNG and will require prior authorization. |
| Evolent Interventional Pain Management and Musculoskeletal Surgery Guidelines | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health Together, Tufts Health RITogether, Tufts Health One Care, tufts Medicare Preferred
| 8/1/2026 | Annual review of Evolent’s guidelines for Interventional Pain Management and Musculoskeletal Surgery. Notable updates include:
|
| Reconstructive and Cosmetic Services | Harvard Pilgrim Commercial
| 8/1/2026 | Criteria and coding updated for reconstructive breast surgery. CPT code 19325 will be covered for additional indications, as identified in the MNG. |
| Solid Organ Transplant | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health Together, Tufts Health RITogether, Tufts Health One Care
| 8/1/2026 | Annual review of MNG. Criteria updated for liver transplant, small bowel transplants, and pancreas transplants consistent with guidelines from the United Network for Organ Sharing and other societies. |
Long Term Supports and Services (LTSS) for Tufts Health One Care Tufts Health Plan Senior Care Options Prior Authorization, Notification, and No Prior Authorization MNG
| Tufts Health One Care, Tufts Health Plan Senior Care Options | 8/1/2026 | Criteria added for personal care attendant meal preparation, which is covered without prior authorization for a maximum of 7 hours per week per MassHealth regulation 130 CMR 422.410(C)(3). Any time beyond 7 hours per week will require prior authorization and a demonstration of medical necessity. Criteria for this authorization has been added to the MNG. |