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Point32Health Medical Necessity Guideline updates
Effective date
Jan 1, 2026
Identified
Jun 20, 2026
Summary
Harvard Pilgrim and Tufts Health Plan Medical Necessity Guidelines changed, and prior authorization is newly required under the Carelon medical benefits management program for a number of codes and services for Harvard Pilgrim Commercial, effective March 1, 2026. Prior authorization was removed for CPT 99501, manual wheelchairs, and oxygen and respiratory therapy equipment effective January 1, 2026, and for Intensity-Modulated Radiation Therapy for all products as of December 31, 2025, because the listed codes are being discontinued.
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What to do
Action · 8 steps
01Already effective March 1, 2026: Obtain prior authorization through the Carelon medical benefits management program for the codes and services listed in the Carelon document for Harvard Pilgrim Commercial members.
02Already effective January 1, 2026: Do not request prior authorization for CPT 99501 (home visit for postnatal assessment and follow-up care) for Harvard Pilgrim Commercial, Tufts Health Plan Commercial and Tufts Health Direct members, because that service is now covered without prior authorization.
03Already effective January 1, 2026: Manual wheelchairs and oxygen and respiratory therapy equipment no longer require prior authorization for the products listed in the update.
04Already effective January 1, 2026: For Uniformed Services Family Health Plan members, procedure codes G0455 and 44705 are covered only when billed with ICD-10 diagnosis codes A04.71 or A04.72, as appropriate.
05Already effective January 1, 2026: Review the updated hematopoietic stem cell transplantation criteria, including pediatric coverage when the member is resistant to tyrosine kinase inhibitors and haploidentical donors when criteria are met.
06Already effective January 1, 2026: Monitored anesthesia care for upper or lower gastrointestinal endoscopy now includes an anticipated prolonged procedure where therapeutic intervention may be involved as a covered scenario.
07Already effective December 31, 2025: Prior authorization is no longer required for IMRT for any product, and Point32Health will provide notice if authorization is reinstated.
08Review the Medical Necessity Guidelines page on the Point32Health provider website for the full coverage and prior authorization criteria.
Codes mentioned
99501G045544705A04.71A04.72
Original notice
Point32Health Medical Necessity Guideline updates
point32health.org · Always check the source before changing claims.
Related changes
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