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

March 2018

Gender Reassignment Services Medical Review Criteria Updates

Effective for dates of service beginning April 1, 2018, Harvard Pilgrim is updating our commercial Gender Reassignment Services Medical Review Criteria, which will be renamed Transgender Health Services Medical Review Criteria.
With the policy update, Harvard Pilgrim will require prior authorization for coverage for all transgender surgical procedures.

Facial feminization coverage expanded

Harvard Pilgrim is expanding the covered indications under the umbrella of facial feminization procedures. The following transfeminine facial surgical procedures will be covered when documentation demonstrates that they are medically necessary for patients with gender dysphoria/gender incongruence: tracheoplasty; blepharoplasty (lower and upper eyelid); blepharoptosis; brow ptosis; rhytidectomy; suction-assisted lipectomy; genioplasty; osteoplasty; otoplasty; rhinoplasty; forehead contouring; and mandible/jaw contouring.

Changes to the list of coverage exclusions

Laryngoplasty will no longer be excluded from coverage; Harvard Pilgrim will provide reimbursement for the procedure when all criteria outlined in the policy are met and the appropriate documentation is provided.

Certain other services are being added to the list of coverage exclusions (including but not limited to abdominoplasty, chemical peels, and dermabrasion. In addition, the voice modification surgery exclusion item is being updated to encompass voice modification therapy as well as surgery.

Breast and chest surgery for trans-adolescents

Additionally, Harvard Pilgrim will give consideration for breast and chest surgeries for trans-adolescents under age 18 who meet all other criteria on the policy.

For complete information, refer to the updated Transgender Health Services Medical Review Criteria.

Correction: The original article noted that this was applicable for Medicare Advantage as well as commercial; however, it is applicable to commercial only at this time.

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2017 Physician Group Honor Roll Announced  


Genetic Testing Authorization Updates

Update: Monitored Anesthesia Care for GI for Endoscopic Procedures

Reminder: UM Decision-Making and Communications

National Healthcare Decisions Day Emphasizes Advance Care Planning

Reminder: Refer Members to Participating Laboratories

Reminder: No Cost Share for Naloxone and Narcan Nasal Spray

Gender Reassignment Services Medical Review Criteria Updates

Updated: Invasive Treatment of Urinary Incontinence Criteria

Updates to Formulas and Enteral Nutrition Medical Review Criteria

Updates to Biofeedback Medical Policy

New Codes Covered for Varicose Veins with Prior Authorization


Reminders and Guidelines when Coding for Cancer

Enhancements to 271 Eligibility Response Transactions

Keep Panel Status and Demographic Information Up to Date

Reminder: Use the Correct Form for Provider Changes for Quicker Service


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