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Harvard Pilgrim Health CareMedicare Advantage · Prior Auth · Prior Authorization · Urology, Radiation Oncology, Cardiology +2 moreHigh impact

Point32Health Medical Necessity Guideline updates

Effective date
Sep 1, 2026
Identified
Sep 2, 2026

Summary

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.

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What to do

Action · 11 steps
01REQUIREMENTS: By 9/1/2026.
02Billing team must update billing software to REMOVE prior authorization requirement for CPT 77437, 77438, and 77439 (radiation oncology codes) from the noncovered investigational services list and configure these codes as covered services.
03For Harvard Pilgrim Commercial only: Configure billing system to NOW REQUIRE prior authorization for CPT 93356 (myocardial strain imaging add-on code) through Evolent vendor program.
04Add validation rule: CPT 93356 must be submitted on same claim with primary code CPT 93307 or 93452.
05Update claim submission guidelines and provider alerts to reflect these changes.
06Billing team must update system to REMOVE prior authorization requirement for CPT 64566 (Percutaneous Tibial Nerve Stimulation) across Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, Tufts Health Together, and Tufts Health RITogether.
07Configure CPT 64566 to be auto-approved when submitted with medically necessary diagnosis codes per Point32Health Medical Necessity Guidelines.
08Behavioral health team must update level of care criteria in system/EMR to incorporate new ASAM 4th Edition adolescent and transition-aged youth treatment settings and updated Adult Level 2.7 Medically Managed Intensive Outpatient Treatment criteria.
09Consequences: Claims submitted with prior authorization requirements for 77437, 77438, 77439, and 64566 after effective dates will be denied.
10Claims for CPT 93356 without prior authorization through Evolent for Harvard Pilgrim Commercial will be denied.
11Claims for 93356 not paired with primary codes 93307/93452 will be denied.

Codes mentioned

64566774377743877439933569330793452

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 →
Point32Health Medical Necessity Guideline updatesHighEffective Jan 1, 2027 · Prior AuthorizationPoint32Health Medical Necessity Guideline updatesHighNo effective date · Prior AuthorizationPoint32Health Medical Necessity Guideline updatesHighEffective Aug 1, 2026 · Prior AuthorizationPoint32Health Medical Necessity Guideline updatesMediumNo effective date · Prior AuthorizationBrowse every Harvard Pilgrim Health Care change in the policy list

Related policy hubs

Harvard Pilgrim Health Care policiesUrologyRadiation OncologyCardiologyPsychiatryPain ManagementCode 64566Code 77437Code 77438Code 77439Code 93356Code 93307Code 93452

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