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 |
| Mobile Cardiac Outpatient Telemetry | Tufts Medicare Preferred, Tufts Health Plan SCO | 1/1/2027 | Prior authorization will be required for codes 93228 and 93229. CMS LCD L34380 will be used for coverage criteria. |
| Stereotactic Radiosurgery and Stereotactic Body Radiotherapy | Tufts Medicare Preferred, Tufts Health Plan SCO | 1/1/2027 | Prior authorization will be required for codes 61796, 61797, 61798, 63620, 63621, 77371, 77372, 77373, 77432, 77435, G0339, and G0340, for new requests submitted on or after Jan. 1, 2027. (Any active treatment underway prior to Jan. 1 will continue to be covered in accordance with our continuity of care policies and will not require prior authorization.) CMS LCD L3576 will be used for coverage criteria. |
| Acupuncture for Pain Management | Tufts Health One Care | 1/1/2027 | Prior authorization will be required for codes 97810, 97811, 97813, and 97814 after the initial 20 visits. Subchapter 4 of the Physician Manual for MassHealth Providers (Physician Providers Regulations) will be used for coverage criteria. |
| Pneumatic Compression Device with Calibrated Gradient Pressure | Tufts Health One Care | 1/1/2027 | Prior authorization will be required for code E0652. NCD - Pneumatic Compression Devices (280.6), and MassHealth DME Provider Manual will be used for coverage criteria. |
| Power Operated Vehicles | Tufts Health One Care | 1/1/2027 | Prior authorization will be required for codes E1230 and K0812. CMS LCD L33789 and NCD 280.3 will be used for coverage criteria. |
| Upper Limb Prostheses | Tufts Health One Care | 1/1/2027 | Prior authorization will be required for codes L6026, L6700, and L6715. Chapter 15 of CMS’s Medicare Benefit Policy Manual will be used for coverage criteria. |
| Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI) | Tufts Medicare Preferred, Tufts Health Plan SCO, Tufts Health One Care | 1/1/2027 | As is currently the case for Commercial products and Tufts Health Public Plans, SCODI will be covered for Tufts Medicare Preferred and Tufts Health Plan SCO only when the criteria outlined on the MNG are met. Tufts Health One Care will be removed from the Commercial and Public Plans MNG and added to this new Senior Products MNG. |
| Vitamin B12 Testing | Tufts Medicare Preferred, Tufts Health Plan SCO | 1/1/2027 | As is currently the case for Commercial products and Tufts Health Public Plans, Vitamin B12 testing will be covered for Tufts Medicare Preferred and Tufts Health Plan SCO only when the criteria outlined on the MNG are met. |
| Vitamin D Testing | Tufts Medicare Preferred, Tufts Health Plan SCO | 1/1/2027 | As is currently the case for Commercial products and Tufts Health Public Plans, Vitamin D testing will be covered for Tufts Medicare Preferred and Tufts Health Plan SCO only when the criteria outlined on the MNG are met. |
| Removal of Benign Skin Lesions | Tufts Health One Care | 1/1/2027 | Removal of benign skin lesions will be covered for Tufts Health One Care only when the criteria identified on the MNG are met, as is currently the case for our Medicare Advantage products Tufts Medicare Preferred and Tufts Health Plan SCO. |
| Tonic Motor Activation for the Treatment of Restless Leg Syndrome | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health Together, Tufts Health RITogether, Tufts Medicare Preferred, Tufts Health Plan SCO, Tufts Health One Care | 11/1/2026 | Criteria updated to remove 6-month trial requirement. In addition, renewal criteria has been removed, as this is considered a purchase only item. |
| Hypoglossal Nerve Stimulation | Tufts Medicare Preferred, Tufts Health Plan SCO | 11/1/2026 | Criteria expanded to include Down Syndrome as a covered indication. |
Noninvasive Prenatal Testing
Genetic Testing – Cell-Free DNA Screening for Fetal Trisomy | Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health RITogether | 11/1/2026 | Prior authorization is no longer required for the noninvasive prenatal testing codes CPT 81420 and 81507, which were previously reviewed by our medical benefits management vendor, Carelon, for Harvard Pilgrim Commercial, Tufts Health Direct, Tufts Health RITogether, and internally for Tufts Health Plan Commercial. As a result, Carelon’s materials will be updated to reflect this change, and our Genetic Testing – Cell-Free DNA Screening for Fetal Trisomy MNG for Tufts Health Plan Commercial will be retired. |