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 | 11/1/2025 | The following will be added to the MNG as non-covered:
The following procedures/services will now be covered without prior authorization:
A number of codes will now be covered only when submitted with ICD-10 diagnosis codes C90.00, C90.01, C90.02 or E85.81. (See MNG for complete details.) For Harvard Pilgrim Commercial, Tufts Health Direct, Tufts Health Together, and Tufts Health RITogether: Codes 0214T— 0218T will now be covered when prior authorization has been obtained through Evolent. For Tufts Health Together and Tufts Health One Care only: CPT code 64555 is now covered without prior authorization. |
| Gender Affirming Services | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health Together, Tufts Health RITogether, Tufts Health One Care | 11/1/2025 | Minor criteria language update related to provider types considered to be qualified health care professionals in the context of the MNG. |