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Point32Health Medical Necessity Guideline updates
Harvard Pilgrim Health Care·Infectious Disease, Audiology, Gastroenterology +6 more·Provider Newsletter
Effective date
Nov 1, 2025
We identified it
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.
Action Required
Before November 1, 2025: Billing team must update system to remove prior authorization requirements for CPT codes 87564, 92517, 92518, 92519, and 0464U. Configure system to require ICD-10 codes C90.00, C90.01, C90.02, or E85.81 for specific covered procedures. Add prior authorization through Evolent for codes 0214T-0218T for Harvard Pilgrim Commercial, Tufts Health Direct, Tufts Health Together, and Tufts Health RITogether plans. Stop billing for Developmental Relationship-Based Intervention for Autism, Blood Test for Amyloid Plaques, and ReActiv8 Neurostimulation as these will be non-covered.