High impact
Point32Health Medical Necessity Guideline updates
Harvard Pilgrim Health Care·Effective Sep 1, 2026
Point32Health has updated four medical necessity guidelines effective 9/1/2026 and 10/1/2026 across multiple plan lines. Key changes include: (1) CPT 64566 (Percutaneous Tibial Nerve Stimulation) no longer requires prior authorization starting 10/1/2026; (2) Radiation oncology CPT codes 77437, 77438, 77439 removed from noncovered investigational list and now covered without prior auth starting 9/1/2026; (3) CPT 93356 (Myocardial strain imaging) now requires prior authorization through Evolent for Harvard Pilgrim Commercial starting 9/1/2026; (4) Behavioral health level of care criteria updated with new ASAM 4th Edition adolescent/youth treatment settings effective 10/1/2026.