Coverage Updates

All products

October 01, 2021  

60-Day Notifications

The following changes are effective for dates of service on or after December 1, 2021:

Cholecystectomy, Laparoscopic
As part of the integration work as a combined organization, Tufts Health Plan is reviewing and assessing existing Harvard Pilgrim Health Care and Tufts Health Plan medical necessity guidelines, both as part of the typical annual review process as well as to assess opportunities for consistency. As part of this review, Tufts Health Plan will require prior authorization for CPT code 47564 for all products. For more information, refer to the Medical Necessity Guidelines for Cholecystectomy, Laparoscopic.

Other Coverage Updates

COVID-19 Antibody (Serological) Testing
Effective for dates of service on or after September 15, 2021, Tufts Health Plan added coverage criteria for FDA authorized COVID-19 antibody testing for all products. Prior authorization is not required. For more information, refer to the Medical Necessity Guidelines for COVID-19 Antibody (Serological) Testing.

MassHealth Evaluation Criteria

Modified T-Cell Therapies
For more information about MassHealth evaluation criteria for the approval of Abecma™, refer to the Medical Necessity Guidelines for Modified T-Cell Therapies. These criteria apply to Tufts Health Together – MassHealth MCO Plan and ACPPs and is effective for dates of service on or after September 15, 2021.

Noncovered Investigational Services

Tufts Health Plan has removed the following services from the Medical Necessity Guidelines for Noncovered Investigational Services as they are now covered services:

  • AlloMap (CPT code 81595) now requires prior authorization.