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 |
| Medical Necessity Guidelines for Temporomandibular Joint (TMJ) Disorder Treatment | Harvard Pilgrim Commercial, Tufts Health Direct, Tufts Health Together, Tufts Health RITogether, Tufts Health One Care | 1/1/2027 | MNG updated to outline coverage and prior authorization criteria for arthroplasty of the TMJ. Prior authorization will be required for the following CPT codes:
In addition, CPT codes 21248, 21249, and 21255 have been removed from the MNG and will no longer require prior authorization. (Consistent with Maine regulations, a redlined version of this policy is also posted temporarily.) |
Sleep Studies for Tufts Health RITogether Positive Airway Pressure Devices for Sleep Apnea (Harvard Pilgrim Commercial) Positive Airway Pressure (PAP) Devices for Tufts Health RITogether and Tufts Health One Care | Harvard Pilgrim Commercial, Tufts Health RITogether, Tufts Health One Care | 12/1/2026 | These MNGs will be retired as a result of the sleep management program updates outlined in detail in this article. HCPCS codes E0470, E0471, and E0601 will no longer require prior authorization for Tufts Health One Care. |
| Implantable Neurostimulators | Harvard Pilgrim Commercial, Tufts Health Direct, Tufts Health Together, Tufts Health RITogether, Tufts Health One Care | 10/1/2026 | Minor criteria language clarification edit. In addition, updated Sacral Nerve Stimulation for Urinary and Fecal Incontinence criteria for Tufts Health One Care only from in-house criteria to CMS criteria. The following local coverage determination (LCD) and national coverage determination (NCD) will be used for criteria: |
Basivertebral Nerve Ablation 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 Health One Care, Tufts Medicare Preferred, Tufts Health Plan SCO | 10/1/2026 | LCD L39642 will no longer be used for coverage criteria, and will be replaced by L40302. |
| Noncovered Investigational Services | Harvard Pilgrim Commercial | 10/1/2026 | BrightSeq Beacon Assay Gene Panel Test added to policy and will no longer be covered. Processed nerve allografts to repair peripheral nerve discontinuities (Avance: acellular nerve allograft-arwx) no longer excluded from coverage. |