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Harvard Pilgrim Health CareCommercial · Prior Auth · Provider Newsletter · Infectious Disease, Audiology, Gastroenterology +6 moreMedium impact

Point32Health Medical Necessity Guideline updates

Effective date
Nov 1, 2025
Identified
Jun 20, 2026

Summary

Point32Health is updating their Medical Necessity Guidelines effective November 1, 2025, making several services non-covered (autism interventions, Alzheimer's blood tests, ReActiv8 neurostimulation) while removing prior authorization requirements for tuberculosis testing, VEMP testing, and Cologuard Plus. Some codes will now require specific diagnosis codes for coverage.

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What to do

Action · 4 steps
01Before November 1, 2025: Billing team must update system to remove prior authorization requirements for CPT codes 87564, 92517, 92518, 92519, and 0464U.
02Configure system to require ICD-10 codes C90.00, C90.01, C90.02, or E85.81 for specific covered procedures.
03Add prior authorization through Evolent for codes 0214T-0218T for Harvard Pilgrim Commercial, Tufts Health Direct, Tufts Health Together, and Tufts Health RITogether plans.
04Stop billing for Developmental Relationship-Based Intervention for Autism, Blood Test for Amyloid Plaques, and ReActiv8 Neurostimulation as these will be non-covered.

Codes mentioned

8756492517925189251964555C90.00C90.01C90.02E85.81

Original notice

Point32Health Medical Necessity Guideline updates
point32health.org · Always check the source before changing claims.
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Related changes

See all Harvard Pilgrim Health Care changes →
Laboratory Payment Policies: June 1, 2026 updatesHighEffective Jun 1, 2026 · ReimbursementPoint32Health Medical Necessity Guideline updatesHighEffective Jan 1, 2027 · Prior AuthorizationPoint32Health Medical Necessity Guideline updatesHighNo effective date · Prior AuthorizationPoint32Health Medical Necessity Guideline updatesHighEffective Sep 1, 2026 · Prior AuthorizationBrowse every Harvard Pilgrim Health Care change in the policy list

Related policy hubs

Harvard Pilgrim Health Care policiesInfectious DiseaseAudiologyGastroenterologyOncologyHematologyNeurologyPain ManagementPsychiatryGeriatricsCode 87564Code 92517Code 92518Code 92519Code 64555Code C90.00Code C90.01Code C90.02Code E85.81

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