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Point32Health Medical Necessity Guideline updates
Effective date
Jan 1, 2027
Identified
Nov 5, 2026
Summary
Point32Health is updating Medical Necessity Guidelines across several plan lines. Effective 11/1/2026 (already in effect as of the 2026-11-05 analysis date), prior authorization is removed for Carelon-reviewed noninvasive prenatal testing codes 81420 and 81507 on certain commercial lines, and the 6-month trial and renewal criteria are removed for tonic motor activation. Effective 1/1/2027 (future), prior authorization is added for multiple codes on Tufts Medicare Preferred, Tufts Health Plan SCO, and Tufts Health One Care, and coverage criteria are added for SCODI, vitamin B12 and D testing, and benign skin lesion removal.
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What to do
Action · 6 steps
01Already effective 11/1/2026: For Harvard Pilgrim Commercial, Tufts Health Plan Commercial, Tufts Health Direct, and Tufts Health RITogether, Billing team: confirm in the prior auth tracker that prior authorization is no longer requested for CPT 81420 and 81507, and update charge entry and claim edits so these claims are not held for an authorization number.
02For tonic motor activation for restless legs, Billing team and providers: confirm the current criteria no longer require a 6-month trial and that renewal documentation is no longer requested for purchase-only requests.
03By 2027-01-01: Before scheduling and before submitting claims, Billing team and providers must check the Point32Health provider website and obtain prior authorization for codes 93228 and 93229 (Tufts Medicare Preferred, Tufts Health Plan SCO), codes 61796, 61797, 61798, 63620, 63621, 77371, 77372, 77373, 77432, 77435, G0339, and G0340 for new requests submitted on or after 1/1/2027 (active treatment underway before 1/1/2027 continues under continuity of care without new authorization), codes 97810, 97811, 97813, and 97814 after the initial 20 visits (Tufts Health One Care), code E0652 (Tufts Health One Care), codes E1230 and K0812 (Tufts Health One Care), and codes L6026, L6700, and L6715 (Tufts Health One Care); in the prior auth tracker and charge entry, flag these codes for these plans.
04Providers and front desk staff should be told about these requirements before scheduling.
05Documentation for SCODI, vitamin B12 and D testing, and benign skin lesion removal should be reviewed against the MNG criteria on the provider website before the effective date, because claims for these services will be covered only when those criteria are met.
06Watch for updates from Point32Health before 2027-01-01.
Codes mentioned
932289322961796617976179863620636217737177372773737743277435G0339G034097810978119781397814E0652E1230K0812L6026L6700L67158142081507
Original notice
Point32Health Medical Necessity Guideline updates
point32health.org · Always check the source before changing claims.
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Related policy hubs
Harvard Pilgrim Health Care policiesMA policy changesCardiologyRadiation OncologyPain ManagementPhysical TherapyOphthalmologyDermatologyInternal MedicineNeurologyPulmonologyFamily MedicineGeriatricsOB-GYNGeneticsPharmacyPathologyOrthopedicsCode 93228Code 93229Code 61796Code 61797Code 61798Code 63620Code 63621Code 77371Code 77372Code 77373Code 77432Code 77435Code G0339Code G0340Code 97810Code 97811Code 97813Code 97814Code E0652Code E1230Code K0812Code L6026Code L6700Code L6715Code 81420Code 81507