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Network Matters
News and Information for the
Harvard Pilgrim Health Care Network

June 2017

Updates to Bariatric Surgeries Medical Review Criteria

Harvard Pilgrim is updating our commercial and StrideSM (HMO) Medicare Advantage medical review criteria for bariatric surgeries. Harvard Pilgrim covers certain bariatric surgeries that are considered medically necessary for morbidly obese adult and adolescent (over 15 years of age) members of our commercial plans, and for morbidly obese Stride members, with prior authorization, when all specified coverage criteria have been met.
Effective for dates of service beginning July 1, 2017, we will no longer cover the following procedure codes, as they are considered experimental/investigational:

  • 43842 — Gastric restrictive procedure, without gastric bypass, for morbid obesity; vertical-banded gastroplasty
  • 43843 — Gastric restrictive procedure, without gastric bypass, for morbid obesity; other than vertical-banded gastroplasty
The updated policies also include additional procedure-specific information and updates to criteria and coverage exclusions.
For more information, and for complete coverage criteria and exclusions, please refer to Harvard Pilgrim’s updated commercial Bariatric Surgeries Medical Review Criteria and StrideSM (HMO) Medicare Advantage Bariatric Surgeries Medical Review Criteria.

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Network Matters Archives

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Changes to Sleep Diagnostic and Sleep Therapy Program

Review of Inpatient Admissions for Appropriate Level of Care

Reminder: Concurrent Review for Inpatient Stays

New Publication on Healthy Eating for Older Adults


Reminder: Expanded Medical Drug Prior Authorization Program

ACA Risk Adjustment Data Validation Reminder: Medical Chart Requests

Update to StrideSM (HMO) Medicare Advantage Hysterectomy Criteria

Updates to Bariatric Surgeries Medical Review Criteria

Updates to Varicose Vein Procedures Medical Review Criteria

Update to Cardiac Event Monitors Medical Policy

Prescribing Statins to Members with Diabetes

Members’ Rights and Responsibilities

Biological Effects of Cannabis and Detriments to Adolescent Development


Telemedicine/Telehealth Payment Policy

Change in Format of Newly Assigned Practitioner and Provider ID Numbers

Credentialing Reminder: Keep Provider Information Up to Date in CAQH

Keep Panel Status and Demographic Information Up to Date


Eric H. Schultz,
President and Chief Executive Officer

Robert Farias,
Vice President, Network Services

Annmarie Dadoly,

Joseph O'Riordan,

Kristin Edmonston,
Production Coordinator