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 |
| Applied Behavioral Analysis (ABA) for Commercial Products and Tufts Health Direct | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health Together | 1/1/2026 | Various changes made to coverage and policies pertaining to applied behavioral analysis therapy service, which vary by product. Please see this article for more detailed information. |
| Genetic and Molecular Diagnostic Testing for Tufts Health Direct, Tufts Health Together, Tufts Health RITogether, and Tufts Health One Care | Tufts Health Direct, Tufts Health Together, Tufts Health RITogether, Tufts Health One Care | 12/1/2025 | List of applicable codes will no longer be maintained on the MNG — you’ll find the most current coding and prior authorization information on Carelon’s provider portal. In addition, we’re making coverage updates related to biomarker codes, in support of guidance from the Massachusetts Executive Office of Health and Human Services. For Tufts Health Together and Tufts Health One Care only, the following CPT codes will be covered with prior authorization:
Prior authorization will be newly required for CPT codes 81514 and 81515. |
| Stereotactic Radiosurgery and Stereotactic Body Radiotherapy | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health Together, Tufts Health RITogether, Tufts Health One Care | 12/1/2025 | Adding primary renal cell carcinoma as a covered indication in alignment with guidelines from the National Comprehensive Cancer Network for kidney cancer. In addition, prior authorization will be newly required for all codes listed on the MNG for Tufts Health RITogether, and prior authorization will be newly required for CPT codes 63620 and 63621 for Tufts Health One Care. |
| Community Support Programs Including Specialized Community Support Programs | Tufts Health Together, Tufts Health One Care, Tufts Health Plan Senior Care Options | 12/1/2025 | We’re updating the notification timeframe requirements outlined on this MNG as follows: CSP: No notification or prior authorization for the first six months of service. Prior authorization must be obtained for coverage to continue beyond the first six months of service. CSP-HI and CSP-TPP: Notification required and must be submitted within one week of initiation of services. Notification is required annually. CSP-JI: Notification required for the first 6 months of service and must be submitted within 3 business days from the first date of service. Prior authorization must be obtained for coverage to continue beyond the first 6 months. |
| Recovery Support Navigator | Tufts Health Together, Tufts Health One Care | 12/1/2025 | We’re updating the notification timeframe requirements outlined on the MNG to specify that notification is required for the first 90 days of service and must be submitted within 7 business days from the first date of service. Prior authorization must be obtained for coverage to continue beyond the first 90 days of service. |
| Continuous Glucose Monitoring and Diabetes Management Devices | Tufts Health One Care | 12/1/2025 | Prior authorization will be required for HCPCS code E2103. In addition, criteria updated to specify that members new to the plan do not need to meet the criteria for “Poorly controlled blood glucose” if they are stable and have been successfully using the device prior to becoming a member and the device was authorized for use by their prior insurance. (Supporting documentation is required.) |
| Lower Limb Prostheses | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health Together, Tufts Health RITogether, Tufts Health One Care | 11/1/2025 | HCPCS code L5783 (adjustable sockets) will now be covered with prior authorization. (This code was previously not covered.) |
| Intensity Modulated Radiation Therapy | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health Together, Tufts Health RITogether, Tufts Health One Care, Tufts Medicare Preferred, Tufts Health Plan Senior Care Options | 10/1/2025 | Minor updates to criteria language.
In addition, intensity modulated radiation therapy is now covered when medically necessary for the following indications: oral cavity, oropharynx, hypopharynx, larynx |
| Clinical Review of Dental Services in the Medical Benefit | Harvard Pilgrim Commercial | 10/1/2025 | Minor criteria updates, and following have been added to the MNG as covered indications:
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| Continuous Glucose Monitoring and Diabetes Management Devices | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health RITogether | 10/1/2025 | Criteria updated to specify that members new to the plan do not need to meet the criteria for “Poorly controlled blood glucose” if they are stable and have been successfully using the device prior to becoming a member and the device was authorized for use by their prior insurance. (Supporting documentation is required.) |
| Percutaneous Electrical Nerve Field Stimulation for Functional Abdominal Pain Disorders — IB-STIM | Tufts Health Together | 10/1/2025 | New MNG providing details on coverage of IB Stim (64999), a percutaneous electrical nerve field stimulator system for use in children and adolescents with abdominal pain associated with irritable bowel syndrome (IBS). MNG is consistent with MassHealth guidance. Prior authorization is not required. |