Point32Health Medical Necessity Guideline updates

REQUIREMENTS: By 9/1/2026: (1) Billing 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. (2) For 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. Add validation rule: CPT 93356 must be submitted on same claim with primary code CPT 93307 or 93452. (3) Update claim submission guidelines and provider alerts to reflect these changes. By 10/1/2026: (1) Billing 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. (2) Configure CPT 64566 to be auto-approved when submitted with medically necessary diagnosis codes per Point32Health Medical Necessity Guidelines. (3) Behavioral 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. Consequences: Claims submitted with prior authorization requirements for 77437, 77438, 77439, and 64566 after effective dates will be denied. Claims for CPT 93356 without prior authorization through Evolent for Harvard Pilgrim Commercial will be denied. Claims for 93356 not paired with primary codes 93307/93452 will be denied.